(CMS-29) Request for Certification as Rural Health Clinic Form and Supporting Regulations

Forms and Documents

Document Name	Status
Form CMS-29 Verification of Clinic Data - Rural Health Clinic Program Form and Supporting Regulations in 42 CFR 491.1-491.11 Form and Instruction	Modified
CMS-29 Final Supporting Statement 1-16-15.doc Supporting Statement A	2015-04-06

IC Document Collections

IC ID	Document Title	Status
7832	Verification of Clinic Data - Rural Health Clinic Program Form and Supporting Regulations in 42 CFR 491.1-491.11 Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0074	ICR Reference No: 201504-0938-006
Status: Historical Active	Previous ICR Reference No: 201202-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: (CMS-29) Request for Certification as Rural Health Clinic Form and Supporting Regulations
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/13/2015
	Date Received in OIRA: 04/08/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2018	36 Months From Approved	05/31/2015
Responses	900	0	864
Time Burden (Hours)	150	0	144
Cost Burden (Dollars)	0	0	0

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Abstract: The Form CMS-29 is utilized as an application to be completed by suppliers of RHC services requesting participation in the Medicare/Medicaid programs. This form initiates the process of obtaining a decision as to whether the conditions for certification are met as a supplier of RHC services. It also promotes data reduction or introduction to and retrieval from the Automated Survey Process Environment (ASPEN) and related survey and certification databases by the CMS Regional Offices.

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Authorizing Statute(s): Statute at Large: 17 Stat. 1875 Name of Statute: null
   Statute at Large: 17 Stat. 1864 Name of Statute: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 3603	01/23/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 16686	03/30/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Verification of Clinic Data - Rural Health Clinic Program Form and Supporting Regulations in 42 CFR 491.1-491.11	CMS-29	Verification of Clinic Data - Rural Health Clinic Program

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ICR Summary of Burden

	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	900	864	0	36	0	0
Annual Time Burden (Hours)	150	144	0	6	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There has been modest growth in the total number of RHCs. The number of RHCs actually completing the form annually has increased from 830 to 900.

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Annual Cost to Federal Government: $4,650

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 04/08/2015

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