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

ICR 201808-0938-008

OMB: 0938-0074

Federal Form Document

ICR Details
0938-0074 201808-0938-008
Active 201803-0938-005
HHS/CMS CCSQ
(CMS-29) Request for Certification as Rural Health Clinic Form and Supporting Regulations
Extension without change of a currently approved collection   No
Regular
Approved with change 09/10/2018
Retrieve Notice of Action (NOA) 08/17/2018
  Inventory as of this Action Requested Previously Approved
09/30/2021 36 Months From Approved 09/30/2018
5,082 0 900
801 0 150
812 0 0

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.

Statute at Large: 17 Stat. 1864 Name of Statute: null
   Statute at Large: 17 Stat. 1875 Name of Statute: null
  
None

Not associated with rulemaking

  83 FR 1037 01/09/2018
83 FR 11753 03/16/2018
No

  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 5,082 900 0 0 4,182 0
Annual Time Burden (Hours) 801 150 0 0 651 0
Annual Cost Burden (Dollars) 812 0 0 0 812 0
Yes
Miscellaneous Actions
No
It is important to note that the burden estimates stated in this PRA package have increased significantly (150 hours to 801 hours) from the burden estimates stated in the previous PRA package submission. This increase in burden is due to several factors. However, this revised burden estimate contains only that burden which is currently and has always been associated with the completion and handling of the initial and survey CMS-29 forms. We have not created nor added any new or additional burden related to the completion of the CMS-29 form that did not previously exist.

$4,849
No
    No
    No
No
No
No
Uncollected
Denise King 410 786-1013 [email protected]

  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.
08/17/2018


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