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

Forms and Documents

Document Name	Status
Form CMS-29 Completion of the initial CMS-29 Form -new RHCs applying to participate in Medicare Program Form and Instruction	Modified
CMS-29 Supporting Statement A (08-17-2018).docx Supporting Statement A	2018-08-17

IC Document Collections

IC ID	Document Title	Status
7832	Completion of the initial CMS-29 Form -new RHCs applying to participate in Medicare Program Form and Instruction	Modified
230989	Medical Secretary to complete mailing for all RHCs surveyed	Modified
230988	Preparation for and mailing of the CMS-29 Form to the State agencies	Modified
230987	Medical Secretary to compulete survey task -RHCs being surveyed	Modified
230986	Photocopying of CMS-29 and filing by a Medical Secretary	Modified
230985	New RHCs review the statutory and regulatory law	Modified
230983	Completion of the Survey CMS-29 Form for state survey agency triennial survey	Modified

ICR Details

OMB Control No: 0938-0074	ICR Reference No: 201808-0938-008
Status: Active	Previous ICR Reference No: 201803-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
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 with change	Conclusion Date: 09/10/2018
	Date Received in OIRA: 08/17/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2021	36 Months From Approved	09/30/2018
Responses	5,082	0	900
Time Burden (Hours)	801	0	150
Cost Burden (Dollars)	812	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. 1864 Name of Statute: null
   Statute at Large: 17 Stat. 1875 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:
	83 FR 1037	01/09/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 11753	03/16/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
New RHCs review the statutory and regulatory law
Preparation for and mailing of the CMS-29 Form to the State agencies
Completion of the initial CMS-29 Form -new RHCs applying to participate in Medicare Program	CMS-29	Verification of Clinic Data - Rural Health Clinic Program
Medical Secretary to compulete survey task -RHCs being surveyed
Medical Secretary to complete mailing for all RHCs surveyed
Photocopying of CMS-29 and filing by a Medical Secretary
Completion of the Survey CMS-29 Form for state survey agency triennial survey

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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	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

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: 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.

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Annual Cost to Federal Government: $4,849

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 08/17/2018

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