| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: XX/XX/20XX |
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CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM
APPLICATION FORM HRSA 99-4
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Public Burden Statement |
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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 12.5 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 10-29, Rockville, Maryland, 20857. |
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Department of Health and Human Services |
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OMB N0. 0915-0247 |
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| Health Resources and Services Administration |
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Expiration Date: XX/XX/20XX |
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| Children's Hospitals Graduate Medical Education Payment Program Government Performance and Results Act (GPRA) Tables |
| Name of Applicant: |
#REF! |
| City: |
#REF! |
State: |
#REF! |
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Zip Code: |
#REF! |
| Medicare Provider Number: |
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#REF! |
| Fiscal Year in which applying for funding: FFY |
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#REF! |
| Type of Application (check box to the left) For submission with Reconciliation Application only. |
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| Table 1. Number of FTE Residents Enrolled in Approved Residency Programs Supported by or Rotating at the Children's Hospital |
| Number of FTE Residents Enrolled in Approved Residency Programs |
Family Medicine Residents |
General Internal Medicine Residents |
Preventive Medicine Residents |
Geriatric Medicine Residents |
Osteopathic General Practice Residents |
General Surgery Residents |
All Other Non-Pediatric Residents |
General Pediatric Residents |
Subspecialty Pediatric Residents (Fellows) |
Total
Non-Pediatric Residents |
Total |
| 1.01 |
Sponsored by the Children's Hospital and Rotating at the Children's Hospital |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
| 1.02 |
Sponsored by the Children's Hospital and Rotating at Non-Provider sites |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
| 1.03 |
Sponsored by Other Hospitals and Rotating at the Children's Hospital |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
| 1.04 |
Sum of Lines 1.01 through 1.03 (above) |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
| 1.05 |
Sponsored by the Children's Hospital and Rotating at Other Hospitals |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
0.00 |
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HRSA 99-4 Page 1 of 2 |
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Created in MS Excel 7.0 |
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(Rev. 04-2016) |
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| Department of Health and Human Services |
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OMB N0. 0915-0247 |
| Health Resources and Services Administration |
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Expiration Date: XX/XX/20XX |
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| Children's Hospitals Graduate Medical Education Payment Program Government Performance and Results Act (GPRA) Tables |
| 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) For submission with Reconciliation Application only. |
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| Table 2. Hospital's Total and Operating Margins |
| Total Margins |
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| Operating Margins |
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| Table 3. Hospital's Allowable Operating Expenses |
| Total Allowable Operating Expenses |
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| Table 4. Hospital's Revenue, Gross Revenue and Expenses Attributed to Patient Care |
| Revenue and Expense Type |
Inpatient |
Outpatient |
| 1. Hospital's gross revenue attributed to Medicaid & SCHIP |
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| 2. Hospital's gross revenue attributed to Medicare |
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| 3. Hospital's gross revenue attributed to self-pay |
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| 4. Hospital's gross revenue attributed to other sources |
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| 5. Hospital's total gross revenue attributed to patient care |
$0.00 |
$0.00 |
| 6. Hospital's total expenses attributed to uncompensated care (bad debt) |
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| 7. Hospital's total expenses attributed to charity care |
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| HRSA 99-4 Page 2 of 2 |
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Created in MS Excel 7.0 |
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| (Rev. 04-2016) |
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