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["Department of Health and Human Services",{"$nulls":6},"OMB N0. 0915-0247"]
["Health Resources and Services Administration",{"$nulls":5},"Expiration Date:  "]
[]
["Children's Hospitals Graduate Medical Education Payment Program                                                                                                                                                               Determination of Indirect Medical Education Data                                                                                 Related to the Teaching of Residents"]
[]
["Name of Applicant:",null,{"$error":"#REF!"}]
["City",{"$error":"#REF!"},"State",{"$error":"#REF!"},null,null,null,"Zip Code:",{"$error":"#REF!"}]
["Medicare Provider Number",null,{"$error":"#REF!"}]
["Fiscal Year in which Applying for Funding:",null,null,"FFY",{"$error":"#REF!"}]
["Type of Application (check box to the left)",null,null,"____Initial Application",null,null,"______Reconciliation Application"]
["Inpatient Data for the Current Medicare Cost Report (MCR) Period"]
[1.01,"Inclusive dates of the current MCR period",null,null,null,"From:",null,"To:"]
[1.02,"Number of Inpatient Days"]
[1.03,"Number of Inpatient Discharges"]
[1.04,"Case Mix Index (CMI)"]
[null,null,null,"Hospitals that elect not to submit a CMI are required to initial the box to the left acknowledging their ineligibility for IME payments.  The initials to the left must be consistent with the signature on HRSA 99-3."]
[]
[]
[]
["IRB Ratio for the Current MCR Period"]
[1.05,"3-year adjusted unweighted resident FTE rolling average for the current MCR period",null,null,null,{"$error":"#REF!"}]
[]
[1.06,"Bed count for the current MCR period",null,null,null,0]
[1.07,"IRB ratio for the current MCR period",null,null,null,0]
["IRB Ratio for the Previous MCR Period"]
[1.08,"Inclusive date of the Current MCR period",null,null,null,"From:",null,"To:"]
[1.09,"Unweighted resident FTE count for the previous MCR period",null,null,null,{"$error":"#REF!"}]
[]
["1.10","Bed count for previous MCR period",null,null,null,0]
[1.11,"IRB ratio for the previous MCR period",null,null,null,0]
["IRB Cap"]
[1.12,"IRB Cap (lesser of 1.07 or 1.11)",null,null,null,0]
[" §422 of the MMA IRB Ratio for the Current MCR Period"]
[1.13,"§422 of the MMA unweighted resident FTE count for the current MCR period",null,null,null,{"$error":"#REF!"}]
[1.14,"Bed count for the current MCR period",null,null,null,0]
[1.15,"§422 of the MMA IRB ratio for the current MCR period",null,null,null,0]
["Outpatient Data"]
[1.16,"Number of Ambulatory Surgery Visits ",null,null,null,0]
[1.17,"Number of Radiology Visits",null,null,null,0]
[1.18,"Number of Urgent Care Visits",null,null,null,0]
[1.19,"Number of Emergency Department Visits",null,null,null,0]
["1.20","Number of Clinic Visits",null,null,null,0]
[]
[]
[]
["HRSA 99-2 PAGE 1 OF 1",{"$nulls":6},"Created in MS Excel 7.0"]
["(Rev. 06-2006)"]