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 |
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
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:
Hospital Website:
D&B D-U-N-S Number:
Contact information for the individual to be notified if the application is funded.
Name:
Title:
Mailing Address:
Telephone Number:
Email Address:
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:
Type
of Application
(check
box to
the left): Initial
Application Reconciliation Application
Contact information for the Director of Graduate Medical Education.
Name:
Title:
Mailing
Address:
Telephone
Number:
Email
Address:
Signature and Date:
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:
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:
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Department of Health and Human Services |
Author | JCook |
File Modified | 0000-00-00 |
File Created | 2023-08-28 |