Hrsa 99-4 Hrsa 99-4

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Overview

422 HRSA 99-1 1
99-4 Page 1
99-4 Page 2

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Sheet 1: 422 HRSA 99-1 1

Department of Health and Human Services							OMB N0. 0915-0247
Health Resources and Services Administration						Expiration Date:
Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts
Name of Applicant:
City:		State:					Zip Code:
Medicare Provider Number:
Fiscal Year in which applying for funding:			FFY
Type of Application (check box to the left)			_____Initial Application			_____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)
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)
				(To)
1.02	Status of MCR
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					#REF!	#REF!	#REF!
2.02	Total unweighted resident FTE count for the hospital's prior cost reporting period					#REF!	#REF!	#REF!
2.03	Total unweighted resident FTE count for the hospital's penultimate cost reporting period					#REF!	#REF!	#REF!
2.04	Rolling average of unweighted resident FTE count					#REF!	#REF!	#REF!
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					#REF!	#REF!	#REF!
2.07	Add On: Unweighted resident FTE count from MMA §422					#REF!	#REF!	#REF!
2.08	Grand Total: Unweighted resident FTE Count					#REF!	#REF!	#REF!
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					#REF!	#REF!	#REF!
3.02	Total weighted resident FTE count for the hospital's prior cost reporting period					#REF!	#REF!	#REF!
3.03	Total weighted resident FTE count for the hospital's penultimate cost reporting period					#REF!	#REF!	#REF!
3.04	Rolling average of weighted resident FTE count					#REF!	#REF!	#REF!
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					#REF!	#REF!	#REF!
3.07	Add On: Weighted resident FTE count from MMA §422					#REF!	#REF!	#REF!
3.08	Grand Total: Weighted resident FTE Count					#REF!	#REF!	#REF!
HRSA 99-1 PAGE 1 OF 4							Created in MS Excel 7.0
(Rev. 06-2006)

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Sheet 2: 99-4 Page 1

Department of Health and Human Services							OMB N0. 0915-0247
Health Resources and Services Administration						Expiration Date:
Children's Hospitals Graduate Medical Education Payment Program Government Performance and Results Act (GPRA) Tables
Name of Applicant:		0
City:	0	State:	0				Zip Code:	0
Medicare Provider Number:		0
Fiscal Year in which applying for funding: FFY
Type of Application (check box to the left) For submission with Reconciliation Application only.
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				General Pediatric Residents	Subspecialty Pediatric Residents (Fellows)		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
1.02	Sponsored by the Children's Hospital and Rotating at Non-Provider sites			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
1.04	Sum of Lines 1.01 through 1.03 (above)			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
Table 2. Hospital's Total and Operating Margins
Total Margins
Operating Margins
HRSA 99-4 PAGE 1 OF 2							Created in MS Excel 7.0
(Rev. 06-2006)

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Sheet 3: 99-4 Page 2

Department of Health and Human Services							OMB N0. 0915-0247
Health Resources and Services Administration						Expiration Date: 01/31/2007
Children's Hospitals Graduate Medical Education Payment Program Government Performance and Results Act (GPRA) Tables
Name of Applicant:		0
City:	0	State:	0				Zip Code:	0
Medicare Provider Number:		0
Fiscal Year in which applying for funding: FFY
Type of Application (check box to the left) For submission with Reconciliation Application only.
Table 3. Hospital's Allowable Operating Expenses
Total Allowable Operating Expenses
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
2. Hospital's gross revenue attributed to Medicare
3. Hospital's gross revenue attributed to self-pay
4. Hospital's gross revenue attributed to other sources
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)
7. Hospital's total expenses attributed to charity care
HRSA 99-4 PAGE 2 OF 2							Created in MS Excel 7.0
(Rev. 06-2006)