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Apply

Application Guidance and Forms

Apply Online > for the 2013 Initial Application. 

The following forms are available for internal use.  Please note that the HRSA Form 99-4 is only mandatory and available for the Reconciliation Application.  

• Application Guidance (PDF - 353 KB)
• HRSA Form 99: Demographic and Contact Information (PDF - 51 KB)
• HRSA Form 99-1 & 99-2: Determination of Weighted and Unweighted Resident Counts (XLS - 138 KB)
• HRSA Form 99-3: Certification (PDF - 104 KB)
• HRSA Form 99-4: Government and Performance Results Act (GPRA) Tables (XLS - 61 KB)
• HRSA Form 99-5: Application Checklist (PDF - 137 KB)

The Initial Application is available on-line on or about July 1 of each Federal fiscal year, and is due on or before August 1 of each Federal fiscal year.

The Reconciliation Application is available online on or about April 1 of each Federal fiscal year, and is due on or before May 1 of each Federal fiscal year.

Please refer to the application guidance before beginning the application. In addition to the on-line application, hospitals must download, complete, sign and mail the demographic form (HRSA Form 99) and a signed certification form (HRSA Form 99-3.)

Direct Medical Education (DME) and Indirect Medical Education (IME) Payments

DME and IME payments are made to eligible institutions during the Federal fiscal year. One third of the appropriated funds are allocated for DME payments and the remaining two thirds are allocated for IME payments. The DME payment will be based on a standardized national average per resident amount and the average number of weighted FTE residents, subject to the resident cap established under the Balanced Budget Act of 1997, and a three years rolling average. The IME payment would vary by hospital.