Medical Education and Research Cost (MERC)
Clinical Training Site Grant Application
Fiscal Year 2014 Trainees
Complete one grant application for each facility providing clinical training in Minnesota. The location providing
clinical training must be actively enrolled in the Minnesota Health Care Program (MHCP), and the address of
training must be consistent with the address enrolled.
(Read training facility instructions before completing.)
MHCP Training
Facility
MHCP Address
City
MN
State
Zip+4
CEO, CFO, or
Authorized Representative
Title
Email Address
(REQUIRED)
Phone
Fax
Mail Potential Grant to Training Site Address Provided Above
Yes
No
*If no, provide CEO, CFO, or Authorized Representative’s mailing address below:
Facility Name
*ATTN:
Address
City
State
MN
Zip+4
MHCP Provider Type
Hospital
Physician Clinic (Not provider-based)
Pharmacy (Retail)
Dental Clinic
Chiropractic Clinic
Other (please specify) ____________
MERC Clinical Training Site Grant Application
Fiscal Year 2014 Training
(Page 2)
Facility:
Federal Tax ID (FEIN)
9 digits
National Provider ID (NPI)
10 digits
Taxonomy / Zip+4
(Only applies to consolidated NPIs)
10 alpha / numeric characters
9 digits
Hospital Subparts – In cases where the hospital has enrolled departments individually with the MHCP, the hospital
IDs must all be listed below for their Medicaid revenue to be included in the hospital’s grant calculation. These
separately enrolled identification numbers must be defined and licensed as a hospital or provider-based hospital clinic
according to CMS guidelines, must be located in Minnesota, and must be included on the hospital’s current Minnesota
license (see memo for details). List each applicable MHCP enrolled facility. Do not include nursing homes or individual
practitioners.
Attach additional sheets if necessary.
Subpart Name
Address (Street, City, Zip)
Separately enrolled in MHCP
MHCP enrolled address
blank
Subpart NPI &
Provider Type
FEIN
blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
Blank
blank
___Check here if additional sheets are attached
MERC Clinical Training Site Grant Application
Fiscal Year 2014 Training
(Page 3)
Funding & Report Requirements: Grant amounts are determined based on the eligibility
criteria and formula defined in Minnesota Statute 62J.692. Funding will be limited to the facility’s
expenses associated with clinical training for qualifying MERC programs in fiscal year 2014. After
initial review of the grant application, MDH will request clinical training expenditures from the CEO,
CFO, or Authorized Representative. This request will be made in November 2015 to the email
address provided on Page 1. Submission of clinical training expenditures are required to process
the application and make awards.
I certify that I am the CEO, CFO or an authorized representative approved by the CEO or CFO of
the facility named above. I have sufficient knowledge about the facility’s MHCP enrollment,
identification numbers used for Medicaid billing, and clinical medical education costs. I attest that
the training facility hosted clinical trainees in fiscal year 2014. I am aware that the data I provide will
be used for grant eligibility and calculations. The data included in the application is accurate and I
will comply with all laws related to MERC statute 62J.692.
Name (print):
Title:
Email:
Signature:
Rev. 07/20/2015
Date: