REQUEST FOR CERTIFICATION AS A RURAL HEALTH CLINIC - RURAL HEALTH CLINIC SURVEY REPORT FORM

ICR 198406-0938-006

OMB: 0938-0074

Federal Form Document

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Document
Name
Status
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IC Document Collections
ICR Details
0938-0074 198406-0938-006
Historical Active 198203-0938-015
HHS/CMS
REQUEST FOR CERTIFICATION AS A RURAL HEALTH CLINIC - RURAL HEALTH CLINIC SURVEY REPORT FORM
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 08/23/1984
Retrieve Notice of Action (NOA) 06/25/1984
  Inventory as of this Action Requested Previously Approved
06/30/1986 06/30/1986
53 0 0
259 0 0
0 0 0

HCFR-29, REQUEST FOR CERTIFICATION AS SUPPLIER OF RURAL HEALTH CLINIC, IS USED BY SUPPLIERS OF RHC SERVICES AS AN APPLICATION TO PARTICIPATE IN THE MEDICARE/MEDICAID PROGRAMS. HCFA-30, RURAL HEALTH CLINIC SURVE REPORT FORM, IS USED BY STATE SURVEY AGENCIES TO RECORD DATA NEEDED TO DETERMINE IF SUPPLIER IS IN COMPLIANCE WITH INDIVIDUAL CONDITIONS OF PARTICIPATION AND TO REPORT IT TO THE FEDERAL GOVERNMENT.

None
None


No

1
IC Title Form No. Form Name
REQUEST FOR CERTIFICATION AS A RURAL HEALTH CLINIC - RURAL HEALTH CLINIC SURVEY REPORT FORM HCFA-29

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 53 0 0 0 53 0
Annual Time Burden (Hours) 259 0 0 0 259 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/25/1984


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