CMS-10790 GME 126 Sample Application

GME 126 Sample Application 



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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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You will need information for the residency pro ram for which your applyin , includin
Contact informatio
ospital CMS Certification um er CC
The Accreditation Council for Graduate Medical Education ACGME accreditation num e
or sheets E, Part A and E- of the most recent as-filed cost report CMS-2 2-10
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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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A federal overnment we site mana ed and paid for y the .S. Centers for
Medicare Medicaid Services. 00 Security oulevard, altimore MD 212
Medicare Electronic Application Request Information System (MEARIS)
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GME 126 Sample Application 

Contact Info

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GME 126 Sample Application

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Application Info

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GME 126 Sample Application

DLC Info

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Eligibility

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• Population HPSA Type

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GME 126 Sample Application

• Population HPSA Type - Option 1 selection

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GME 126 Sample Application

• Population HPSA Type - Option 2 selection

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GME 126 Sample Application

• Population HPSA Type - Option 3 selection

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Geographic HPSA Type

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GME 126 Sample Application

• Geographic HPSA Type - Option 1 selection

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GME 126 Sample Application

• Geographic HPSA Type - Option 2 selection

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GME 126 Sample Application

• Geographic HPSA Type - Option 3 selection

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Supporting Documents

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Attestation

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GME 126 Sample Application

Confirmation

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GME 126 Sample Application