Form 99-5 I & R 99-5 I & R HRSA 99-5 (Initial and Reconciliation)

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 99-5

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 1.55 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.

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 Checklist

Name of Applicant: Medicare Provider Number:

FFY in which Applying for CHGME PP Funding: FFY

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

Application Forms and Supporting Documentation

This Column to be Completed by the Applicant Hospital

This Column to be Completed by the CHGME PP

Is the Listed Item Completed and Attached?

Forms and Supporting Documentation Required to be Submitted by All Participating Hospitals

HRSA-99 (2 pages) Yes No Yes No

HRSA 99-1 (4 pages) Yes No Yes No

HRSA 99-2 (1 page) Yes No Yes No

HRSA 99-3 (6 pages) Yes No Yes No

HRSA 99-4 (2 pages) – Required at Reconciliation only Yes No Yes No

HRSA 99-5 (1 page) Yes No Yes No

Computer Disk Containing Completed HRSA Forms Yes No Yes No

One (1) Copy of the Hospital’s Completed Application Package. The copy should include all required forms and supporting documentation s presented in the original package.

Yes No Yes No

Additional Supporting Documentation

The forms and supporting documentation listed below may not applicable to all hospitals.

Hospitals should contact their CHGME PP regional manager for assistance and/or clarification.

Cover letter detailing any issues that may impact the processing or approval of the children’s hospital’s application for CHGME PP funding.

CMS 2552-96 MCR Worksheet E-3, Part IV(s)

Required for each cost reporting period identified in the HRSA 99-1 in which the hospital filed a full MCR.

Affiliation Agreement for an Aggregate Cap

Required for each cost reporting period identified in the HRSA 99-1 in which the hospital established a Medicare GME Affiliation Agreement. Please ensure that the most recent version/update is provided (i.e., reflecting any adjustments made to the agreement during the academic year).

CMS Letter(s) addressing changes to the Hospital’s 1996 Base Year Cap as a result of

§422 of the MMA and/or §5503 of the ACA (increases and/or decreases).

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

HRSA 99-5 Page 1 of 1 Created in MS Word 6.0

(Rev. 04-2016)