Request for Certification as Rural Health Clinic and Rural Health Clinic Survey Report Form and Supporting Regulations in 42 CFR 491.1-491.11

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0074 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-29 Request for Certification as Rural Health Clinic and Rural Health Clinic Survey Report Form and Supporting Regulations in 42 CFR 491.1-491.11 Form and Instruction
CMS-29 Request to Establish Eligibility to Participate in the H cms29 form and instructions.pdf Form and Instruction

Information Collection (IC) Details

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IC Title:	Request for Certification as Rural Health Clinic and Rural Health Clinic Survey Report Form and Supporting Regulations in 42 CFR 491.1-491.11	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-29	Request to Establish Eligibility to Participate in the Health Insurance for the Aged and Disabled Program to Provide RHC Services	cms29 form and instructions.pdf		No	No	Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 766	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	766	68	698
Annual IC Time Burden (Hours)	192	-1,030	1,222
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.