(CMS-R-38) Medicare and Medicaid Programs: Conditions for Certification for Rural Health Clinics in 42 CFR 491

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS R-38 Final Supporting Statement - Passback3.docx	Supporting Statement A	Uploaded 2017-05-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7968	491.9(b)(3) Patient Care Policies		Modified
45407	491.9(b)(3) Patient Care Policies		Modified
190717	491.11 Program Evaluation		Modified
190716	491.11 - Program Evaluation		Modified

ICR Details

OMB Control No: 0938-0334	ICR Reference No: 201701-0938-008
Status: Historical Active	Previous ICR Reference No: 201309-0938-024
Agency/Subagency: HHS/CMS	Agency Tracking No: 20561
Title: (CMS-R-38) Medicare and Medicaid Programs: Conditions for Certification for Rural Health Clinics in 42 CFR 491
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 with change	Conclusion Date: 06/08/2017
	Date Received in OIRA: 01/31/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	8,656	0	9,716
Time Burden (Hours)	37,216	0	33,304
Cost Burden (Dollars)	0	0	0

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Abstract: This information is needed to determine if rural health clinics meet the requirements to participate in the Medicare Program.

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Authorizing Statute(s): None

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:
	81 FR 76945	11/04/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 4887	01/17/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
491.9(b)(3) Patient Care Policies
491.9(b)(3) Patient Care Policies
491.11 - Program Evaluation
491.11 Program Evaluation

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ICR Summary of Burden

table that charts list 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	8,656	9,716	0	0	-1,060	0
Annual Time Burden (Hours)	37,216	33,304	0	0	3,912	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: There have been changes in the number of Rural Health Clinics. The increase in burden costs results solely from the increase in benefits and overhead package costs that were calculated at 100% of the annual salary for the applicable occupations.

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Annual Cost to Federal Government: $0

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: 01/31/2017

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