| 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: |
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| Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts |
| Name of Applicant: |
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| City: |
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State: |
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Zip Code: |
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| Medicare Provider Number: |
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| Fiscal Year in which applying for funding: |
FFY |
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| Type of Application (check box to the left) |
_____Initial Application |
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_____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) |
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| 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) |
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| (To) |
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| 1.02 |
Status of MCR |
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| 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 |
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| HRSA 99-1 PAGE 1 OF 4 |
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Created in MS Excel 7.0 |
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| (Rev. 06-2006) |
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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: 01/31/2007 |
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| 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 |
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| 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) |
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| (To) |
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| 4.02 |
Status of MCR |
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| 4.03 |
Unweighted resident FTE count for allopathic and osteopathic programs (from the cap year) |
0.00 |
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0.00 |
0.00 |
| 4.04 |
Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) |
0.00 |
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0.00 |
0.00 |
| 4.05 |
Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs |
0.00 |
0.00 |
0.00 |
| 4.06 |
FTE adjusted cap |
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 |
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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 |
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| HRSA 99-1 PAGE 2 OF 4 |
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Created in MS Excel 7.0 |
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| (Rev. 06-2006) |
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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: |
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| 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 |
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| 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) |
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| (To) |
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| 5.02 |
Status of MCR |
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| 5.03 |
Unweighted resident FTE count for allopathic and osteopathic programs |
0.00 |
0.00 |
0.00 |
| 5.04 |
Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) |
0.00 |
0.00 |
0.00 |
| 5.05 |
Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs |
0.00 |
0.00 |
0.00 |
| 5.06 |
FTE adjusted cap |
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 4.06 and 4.07 |
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 |
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| HRSA 99-1 PAGE 3 OF 4 |
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Created in MS Excel 7.0 |
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| (Rev. 06-2006) |
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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: |
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| 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 |
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| 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) |
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| (To) |
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| 6.02 |
Status of MCR |
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| 6.03 |
Unweighted resident FTE count for allopathic and osteopathic programs |
0.00 |
0.00 |
0.00 |
| 6.04 |
Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) |
0.00 |
0.00 |
0.00 |
| 6.05 |
Adjustment (to the cap) for the Unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs |
0.00 |
0.00 |
0.00 |
| 6.06 |
FTE adjusted cap |
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 4.06 and 4.07 |
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 |
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| HRSA 99-1 PAGE 4 OF 4 |
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Created in MS Excel 7.0 |
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| (Rev. 06-2006) |
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