CMS-10790 GME 126 Sample Application

Distribution of GME Residency Positions Under Section 126 of the Consolidated Appropriations Act (CAA), 2021, and Section 4122 of the CAA, 2023 (CMS-10790)

GME 126 Sample Application Final

GME Applications

OMB: 0938-1417

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GME 126 Sample Application 



Welcome Page 


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Welcome to the Graduate Medical Education (GME) Section 126 Application

for Fiscal Year 2023

Important Information
The application period for GME full-time equivalent positions awarded in FY 2023 ends on March 31, 2022. 


ositions a arded under section 126 for FY 202

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All fields are required unless marked as optional.

This application form saves automatically, so that you may continue where you left off.

Eligi ility criteria and other information on section 126 of the onsolidated Appropriations Act may e found at
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PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-XXXX(Expires: XX/XX/XXXX). This is a
voluntary information collection. The time required to complete this information collection is estimated to average 8 hours per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.


CMS Disclosure


Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports
Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact the CMS point of contact for this module using the form available at the bottom of the
page..
MEARIS™ Section 126 resources page

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Medicare Electronic Application Request Information System (MEARIS)
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• Population HPSA Type

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Geographic HPSA Type

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Supporting Documents

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Attestation

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Confirmation

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File Modified2022-03-07
File Created2022-03-07

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