Supporting Statement A (Extension)
Verification of Clinic Data – Rural Health Clinic Program
Form CMS-29 / PRA Package #0938-0074
A. Background
The information collection requirements that are included with this request are for the currently approved collection, Verification of Clinic Data – Rural Health Clinic Program Form CMS-29 (for which extension of previous approval is being requested).
The Form CMS-29, Verification of Clinic Data – Rural Health Clinic Program is utilized as an application to be completed by suppliers of Rural Health Clinic (RHC) services requesting participation in the Medicare program. 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 (ROs). Should any question arise regarding the structure of the organization, this information is readily available.
Both new and existing clinics must provide and attest to the accuracy of specific clinic data as a part of the RHC certification process. Therefore, we are requesting to extend the existing approval. However, we have revised the burden estimate for this PRA package because we believe that the previous burden estimate did not provide an accurate picture of all burden related to this ICR.
B. Justification
1. Need and Legal Basis
Collection of this information is authorized by 42 CFR 491.1 through 491.12 pursuant to sections 1864 and 1875 of the Social Security Act. Organizations rendering RHC services may participate as Medicare suppliers. In order to determine compliance with the conditions for certification (CfC), the Secretary has authorized States through contracts to conduct surveys of health care suppliers. For Medicare purposes, certification is based on the State agency's recording and reporting to CMS of a supplier's compliance or noncompliance with health and safety requirements.
The Verification of Clinic Data – Rural Health Clinic Program, Form CMS-29, is a certification form provided by the State agency to those clinics seeking Medicare certification as a RHC. It is completed and returned by the applicant and evaluated subsequently through an on-site survey. The State agency has an inspector/surveyor review the facility's compliance with the RHC CfCs.
The verification form also details the clinic information which will be stored in the ASPEN and related survey and certification databases. The storage of the information allows for later retrieval for study reports and data collection.
2. Information Users
CMS uses the collected information to inform its certification and recertification decisions. When a clinic seeks certification in the Medicare program as a RHC, the State agency forwards the Verification of Clinic Data (CMS-29) to the clinic which completes and returns the form. The information on the completed form serves as an initial screening tool for the State agency to determine if the clinic appears to satisfy basic certification requirements and is ready for a more detailed on-site compliance assessment.
3. Improved Information Technology
The basic identifying information from this form is incorporated into ASPEN and related survey and certification databases and serves as the information base for the creation of a record for future Federal recertification and analytical activity.\
However, the CMS-29 itself is in a non-fillable .pdf format that the RHC must download from the CMS website. The facility is required to fill in the following information on the CMS-29 form via handwriting or typewriter: (1) CCN number; (2) State/County; (3) State Region (4) full address and telephone number; (5)Name and address of clinic owners; (6) Medical Direction which included the type of clinic personnel; (7) type of control ( i.e. – individual, corporation, partnership or government); (8) indication as to whether the RHC is a provider-based entity to a hospital or critical access hospital (CAH); and if so, (9) state the CCN number of the hospital/CAH
The RHC is required to send the completed and signed original copy of the completed and signed CMS-29 form to the State Survey Agency (SA). Therefore, this form does not lend itself to electronic signature or electronic submission at this time. However, if, a later date, CMS considers converting this form to electronic submission, electronic signatures could be used.
4. Duplication of Similar Information
The CMS-29 does not duplicate any information collection. The form addresses unique regulatory CfCs that RHCs must meet to participate in the Medicare program. State agencies receive Federal funds for conducting these reviews under contract with CMS. This form is a basic deliverable under these contracts and is the only one of its kind collected by CMS for RHC suppliers.
5. Small Business
Approximately 98% of RHCs are small businesses. The information collected is needed to assist in determining the RHC’s compliance with the CfCs. Collection of this information imposes a minimal burden and thus does not significantly affect small businesses.
The completion of the CMS-29 form is required when a RHC seeks participation in the Medicare program and also when the SA performs a survey of the RHC. These surveys are performed approximately once every 3 years therefore, the small business RHC’s will only be required to complete the CMS-29 form upon application for participation in the Medicare program and once every three years thereafter. If the information has not changed from the last CMS-29 form filed, the small business RHC could simply copy or scan the previous form and add an original signature, which would decrease the time burden associated with the completion of this form on a triennial basis.
6. Less Frequent Collection
This information is collected prior to the clinic’s initial certification, and subsequently once every three years on average, when the State agency conducts a recertification survey. Less frequent surveys and associated verification of the Form CMS-29 could reduce quality assurance protections to Medicare beneficiaries.
7. Special Circumstances for Information Collection
There are no special circumstances associated with this collection. These requirements comply with all general information collection guidelines in 5 CFR 1320.6.
8. Federal Register and Outside Consultation
A 60-day Federal Register notice was published on January 9, 2018 (83 FR 1037). No comments were received
The 30-day Federal Register notice published on March 16, 2018 (83 FR 11753). No comments were received.
9. Payments or Gifts
There are no payments of gifts associated with this collection.
10. Confidentiality
We do not pledge confidentially
11. Sensitive Questions
There are no questions of a sensitive nature associated with this form.
12. Estimate of Burden
Time Burden Estimate:
As noted above, the completion of the CMS-29 form is required when a RHC seeks participation in the Medicare. We estimate that there are approximately 210 new RHCs seeking participation in the Medicare program each year. This information was obtained from the CMS Survey & Certification Quality, Certification and Oversight Reports website (https://qcor.cms.gov/main.jsp)
An RHC must also complete a CMS-29 when the SA performs a survey. These surveys are supposed to be performed once every 3 years. Currently, thus far in CY 2018, there are 4,243 RHCs enrolled in the Medicare Program. We estimate that approximately one-third of existing RHCs would be surveyed per year which would provide for a survey of each RHC every 3 years.
Time for Completion of the “Initial” CMS-29 Form When An RHC Is Applying for Participation in the Medicare Program
We estimate that it takes the RHC approximately 20 minutes to complete the initial CMS-29 form when an RHC is applying for participation in the Medicare Program.
Currently there are 4,243 RHC’s. There are approximately 210 new RHC’s per year. We estimate that it would take 70 hours across all new RHCs per year to complete the initial CMS-29 forms
210 new RHCs per year x 20 minutes per new RHC per CMS-29 form = 4,200 minutes per all new RHCs per year
4,200 minutes per all new RHC’s per year divided by 60 minutes per hour = 70 hours per all new RHCs per year.
Time for Completion of the “Survey” CMS-29 Form When State Survey Agency (SA) Performing Triennial Survey
We estimate that approximately one-third of existing RHCs would be surveyed per year which would allow for a survey of each RHC every 3 years. There are currently 4,243 RHCs and we estimate that approximately 1,414 of the RHCs are surveyed by the SA each year and must complete the CMS-29 forms as part of this survey.
We estimate the time required for the RHCs being surveyed to complete the CMS-29 is 10 minutes. We believe that the time for completion of this form would be less that the time required for the completion of the initial form for several reasons. First, the RHC has already filled out the CMS-29 before and would be familiar with this form and what must be filled out. Second, the RHC should have a copy of the CMS-29 previously filled out and can use it as a sample from which to get information to complete the currently required CMS-29 form. In fact, if there is no change in the information to be placed on the currently required CMS-29 form, the RHC could copy or scan the previous form and add an original signature and current date. Further, we would not attribute time in our burden estimate for review of the statutory and regulatory law as the RHC should have reviewed this when the initial CMS-29 form was filled out and may have had reason to do so at various times since that time for other reasons.
We estimate that the time required for each RHC being surveyed in a given year to complete the CMS-29 form is 10 minutes. We further estimate that the time required across all RHCs being surveyed per year to complete the CMS-29 form is 236 hours
10 minutes per CMS-29 form x 1,414 RHCs being surveyed = 14,140 minutes per all RHCs being surveyed per year to complete the CMS-29 form
14,140 minutes per all RHCs being surveyed per year to complete the CMS-29 form divided by 60 minutes per hour = 236 hours per all RHCs being surveyed per year to complete the CMS-29 form
Time Required for New RHCs Completing the CMS-29 Form to Review The Statutory and Regulatory Law Associated With This Form
We believe that a new RHC that is completing the CMS-29 form for the first time must become familiar with the statutory and CMS regulations associated with this form. Therefore, we have estimated that it would take approximately 25 minutes for each new RHC to review and become familiar with the statutory and CMS regulatory law associated with an RHC’s participation in the Medicare program. We further estimate that it would take 88 hours of time across all new RHCs for this review:
210 new RHCs x 25 minutes = 5,250 minutes
5,250 minutes divided by 60 minutes per hour = 88 hours per all new RHCs to complete review of statutory and regulatory law.
It is important to note that we have not assessed this time burden for RHCs that have previously completed the CMS-29 form as we assume that they have already researched and become familiar with the applicable statutory and CMS regulatory law.
Time Required for Photocopying of Original Copy of CMS-29 and Filing of Copy by a Medical Secretary
After the CEO has completed and signed the CMS-29, we estimate that it would next be given to a Medical Secretary for photocopying and filing of the copy. We estimate that this would take 5 minutes.
We estimate that the time required for all a Medical Secretary to complete this task across all new RHCs would be 18 hours:
210 new RHCs per year x 5 minutes per new RHC per CMS-29 form = 1,050 minutes per all new RHCs per year
1,050 minutes per all new RHC’s per year divided by 60 minutes per hour = 18 hours per all new RHCs per year).
We further estimate that the time required for all a Medical Secretary to complete this task across all RHCs being surveyed would be 118 hours:
1,414 RHCs being surveyed/year x 5 minutes per each CMS-29 form = 7,070 minutes per all RHCs being surveyed per year
7,070 minutes per all RHCs being surveyed per year divided by 60 minutes per hour = 118 hours per all RHCs being surveyed per year.
Time Required for the Preparation for and Mailing of the CMS-29 Form to the State Agency by a Medical Secretary
It is required that the RHC send the original copy of the CMS-29 form the SA. Therefore, we estimate that after a photocopy of the original, completed and signed CMS-29 form has been made, a Medical Secretary will prepare the CMS-29 form for mailing (i.e., - preparing a mailing envelope addressed to the SA, putting the form into the envelope, sealing the envelope) and putting the envelope into the outgoing mail). We believe that these activities will take approximately 10 minutes.
We estimate that the time required for all a Medical Secretary to complete this task across all new RHCs would be 35 hours:
210 new RHCs per year x 10 minutes per new RHC per CMS-29 form = 2,100 minutes per all new RHCs per year
2,100 minutes per all new RHC’s per year divided by 60 minutes per hour = 35 hours per all new RHCs per year).
We further estimate that the time required for all a Medical Secretary to complete this task across all RHCs being surveyed would be 236 hours:
1,414 RHCs being surveyed per year x 10 minutes per each CMS-29 form = 14,140 minutes per all RHCs being surveyed per year
14,140 minutes per all RHCs being surveyed per year divided by 60 minutes per hour = 236 hours per all RHCs being surveyed per year).
Summary of Total Time Burdens
Total Time Required For Preparation and Mailing of the “Initial” CMS-29 Form
Preparation (i.e. – Review, fill in information, sign & date) by CEO: 20 minutes
Review of Statutory and CMS Regulatory law by CEO 25 minutes
Copying for form and filing of copy by Medical Secretary 5 minutes
Preparation for mailing and putting into mail by Medical Secretary 10 minutes
TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 60 minutes
Total Time Required for the Preparation and Mailing of the “Survey” CMS-29 Form
Preparation (i.e. – Review, fill in information, sign & date) by CEO: 10 minutes
Copying for form and filing of copy by Medical Secretary 5 minutes
Preparation for mailing and putting into mail by Medical Secretary 10 minutes
TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 25 minutes
Total Time Required for Preparation and Mailing of the “Initial” CMS-29 Form Across All New RHC’s Per Year
Preparation (i.e. – Review, fill in information, sign & date) by CEO: 70 hours
Review of Statutory and CMS Regulatory law by CEO 88 hours
Copying for form and filing of copy by Medical Secretary 18 hours
Preparation for mailing and putting into mail by Medical Secretary 35 hours
TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 211 hours
Total Time Required for the Preparation and Mailing of the “Survey” CMS-29 Form Across All RHCs Being Surveyed Per Year
Preparation (i.e. – Review, fill in information, sign & date) by CEO: 236 hours
Copying for form and filing of copy by Medical Secretary 118 hours
Preparation for mailing and putting into mail by Medical Secretary 236 hours
TOTAL TIME FOR PREPARATION OF INITIAL CMS-29 590 hours
Financial Burden Estimates:
Cost for Time for Completion of the “Initial” CMS-29 Form When An RHC Is Applying for Participation in the Medicare Program
We believe that a Chief Executive Officer or comparable senior official authorized by the facility would be expected to sign the CMS-29. According to the U.S. Bureau of Labor Statistics, the mean hourly wage for a Chief Executive Officer is $94.25 (https://www.bls.gov/oes/2017/may/oes111011.htm).
As noted above, we estimate that the time required to prepare the initial CMS-29 form (i.e. – read, fill in the required information, sign and date) is 20 minutes. We also attributes an additional 25 minutes for the signer of the CMS-29 form to review and become familiar with the relevant statutory and CMS regulatory law associated with the CMS-29 form and participation in the Medicare Program by an RHC. This equates to a total of 45 minutes for preparation of the initial CMS-29 form by the RHC’s CEO
We estimate that the cost for preparation of the initial CMS-29 form by a Chief Executive Office would be $70.65 per each form ($31.40 + $39.25):
$94.25 divided by 60 minutes per hour = $1.57 per minute
$1.57 per minute x 20 minutes to review, complete and sign CMS-29 form = $31.40
We estimate the cost for review of the relevant statutory and CMS regulatory law by a Chief Executive Office prior to the preparation of the CMS-29 would be $39.00 per each form:
$94.25 divided by 60 minutes per hour = $1.57 per minute
$1.57 per minute x 25 minutes for review of the regulatory & statutory law = $39.25.
We estimate that the cost across all new RHCs for the completion of the initial CMS-29 form by the RHC’s CEO would be $14,836.50:
$70.65 x 210 new RHC’s per year = $14,836.50
Cost for Completion of CMS-29 Form When The State Survey Agency (SA) Performs A Triennial Survey (referred to as the “Survey CMS-29 Form”)
We estimate that the time required to prepare (i.e. – read, fill in the required information, sign and date) the initial CMS-29 form is 10 minutes. However, we do not attributes any additional time for the signer of the CMS-29 to review and become familiar with the statutory and CMS regulatory law associated with the CMS-29 form when this form is being completed by an RHC for a subsequent survey, because we believe that they should already be familiar with said law by this time. We assume that the RHC’s CEO would have reviewed the relevant law previously when completing the initial CMS-29 form.
We estimate the cost for preparation of the survey CMS-29 form by the RHC’s CEO would be $15.70 per each form:
$94.25 divided by 60 minutes per hour = $1.57 per minute
$1.57 per minute x 10 minutes = $15.70.
The cost across all RHCs being surveyed would be $22,199.80:
$15.70 cost per each RHC x 1,414 RHCs being surveyed per year $22,199.80.
Cost for Photocopying of Original Copy of CMS-29 and Filing of Copy by a Medical Secretary
As stated above, we believe that after completion of the CMS-29 by the CEO, a Medical Secretary will photocopy this form and file the copy. According to the U.S. Bureau of Labor Statistics, the mean average hourly wage for a Medical Secretary is $17.25 (https://www.bls.gov/oes/2017/may/oes436013.htm). We estimate that it will take a Medical Secretary approximately 5 minutes to photocopy the completed CMS-29 form and file this photocopy.
We estimate that the cost for these tasks would be $1.45:
$17.25 divided by 60 minutes per hour = $1.45 per minute
$0.29 per minute x 5 minutes per each CMS-29 form = $1.45 per each RHC.
The cost across all RHCs filing an initial CMS-29 would be $304.50:
$1.45 per each CMS-29 form x 210 new RHCs = $304.50 per all new RHCs
The cost across all RHCs filing a survey CMS-29 would be $2,050.30:
$1.45 per each CMS-29 form x 1,414 RHCs being surveyed = $2,050.30
Cost for the Preparation for and Mailing of the CMS-29 Form to the State Agency by a Medical Secretary
As stated above, we believe that after completion of the CMS-29 by the CEO, a Medical Secretary will prepare the CMS-29 form for mailing and put it into the outgoing mail. We estimate that it will take a Medical Secretary approximately 10 minutes to photocopy the completed CMS-29 form and file this photocopy.
We estimate that the cost for these tasks would be $2.90:
$17.25 per hour divided by 60 minutes per hour = $0.29 per minute
$0.29 per minute x 10 minutes = $2.90 per each CMS-29 form per RHC.
The cost across all RHCs filing an initial CMS-29 would be $609:
$2.90 per each CMS-29 form x 210 new RHCs = $609 across all new RHCs
The cost across all RHCs filing a survey CMS-29 would be $4,100.60:
$2.90 per CMS-29 form x 1,414 RHCs being surveyed = $4,100.60 across all RHC’s being surveyed
Fringe Benefits For Wages
We estimate that there will be fringe benefits incurred on the wages at a rate of 100% of the gross wages.
We estimated that the total wages for the preparation of the “initial” CMS-29 form across all new RHCs would be $15,750.00. Therefore, we have added the amount of $15,750.00 to our burden estimate for fringe benefits related to the wage costs for the preparation of the “initial” CMS-29 form.
We estimated that the total wages for the preparation of the “survey” CMS-29 form across all new RHCs would be $28,350.70. Therefore, we have added the amount of $28,350.70 to our burden estimate for fringe benefits related to the wage costs for the preparation of the “survey” CMS-29 form.
Non-Labor Related Costs
Each new RHC that completes a CMS-29 must mail an original copy of the completed form to the State Survey Agency. This will require the facilities will incur costs for one first-class postage stamp or postage meter postage mark which would cost $0.50.
We estimate that the cost of postage across all RHCs filing an initial CMS-29 would be $105
$0.50 x 210 = $105
We further estimate that the cost of postage across all RHCs filing a survey CMS-29 would be $707
$0.50 x 1,414 = $707
Summary of Costs Burdens for Completion of the Initial and Survey CMS-29 Forms.
Total Cost for Preparation and Mailing of Each “Initial” CMS-29 Form
Preparation (i.e. – Review, fill in information, sign & date) by CEO: $ 31.40
Review of Statutory and CMS Regulatory law by CEO: $ 39.25
Copying for form and filing of copy by Medical Secretary: $ 1.45
Preparation for mailing and putting into mail by Medical Secretary: $ 2.90
Fringe Benefits on Wages (100% of Total Wages): $ 75.00
Non-Labor Related Costs: $ 0.50
TOTAL COST: $150.50
Total Cost for the Preparation and Mailing of All Initial CMS-29 Form Across All New RHC’s
Preparation (i.e. – Review, fill in information, sign & date) by CEO: $ 6,594.00
Review of Relevant Statutory and Regulatory Law: $ 8,242.00
Copying for form and filing of copy by Medical Secretary: $ 304.50
Preparation for mailing and putting into mail by Medical Secretary: $ 609.00
Fringe Benefits on Wages (100% of Total Wages): $15,750.00
Non-Labor Related Costs (Postage): $ 105.00
TOTAL COST $31,605.00
Total Cost for the Preparation and Mailing of Each Survey CMS-29 Form
Preparation (i.e. – Review, fill in information, sign & date) by CEO: $15.70
Copying for form and filing of copy by Medical Secretary: $ 1.45
Preparation for mailing and putting into mail by Medical Secretary: $ 2.90
Fringe Benefits on Wages (100% of Total Wages): $20.05
Non-Labor Related Costs: $ 0.50
TOTAL COST $40.60
Total Cost for the Preparation and Mailing for ALL Survey CMS-29 Forms Across All RHC’s Being Surveyed
Preparation (i.e. – Review, fill in information, sign & date) by CEO: $22,199.80
Copying for form and filing of copy by Medical Secretary: $ 2,050.30
Preparation for mailing and putting into mail by Medical Secretary: $ 4,100.60
Fringe Benefits on Wages (100% of Total Wages): $28,350.70
Non-Labor Related Costs (Postage): $ 707.00
TOTAL COST $57,408.40
13. Capital Costs
There are no capital costs.
14. Cost to Federal Government
Total Federal Cost - $4,849.00*
Number of suppliers in universe 4,243
Number of new suppliers completing form annually 210
Number of existing suppliers completing form annually 1,414
Contracting costs to complete forms $3,949
Printing of forms CMS-29 and Distribution: $9001
The cost for review and analysis of forms was calculated using an average hourly salary of $28.82/hour for state survey inspectors2, an average of 0.1667 hours for surveyors’ verification and an annual workload of 210 / (137 hours times x $28.82 = $3,949.)
15. Burden Changes/Program changes
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.
First, the increase in burden is, in most part, due to the fact that our current burden estimate contains a more detailed estimate of the time and cost burdens associated with the completion of the initial and survey CMS-29 forms which is in accordance with the definition of “burden” set forth in 5 CFR 1320.3(b)(1). This estimate was performed using 5 year average of the number of new RHCs and the number of RHCs being surveyed. We believe that it is necessary to provide a more detailed and accurate picture of the time and cost burdens related to the completion of the initial and survey CMS-29 forms, because the prior burden estimate included only the time required for review and signature of the CMS-29 form. The previous PRA package’s burden estimate did not clearly delineate all steps in the process of filling in and completing the CMS-29 form, such as: (1) the time and cost required for the RHC’s CEO to review, fill-in and sign the CMS-29 form; (3) the time and cost required for the CEO to review the relevant statutory and regulatory law associated with the CMS-29 form; (3) the time and costs for a Medical Secretary to make a photocopy of the completed and signed CMS-29 form; (4) the time and cost required for a Medical Secretary to prepare a mailing envelope addressed to the State Survey Agency, affix postage to the envelope, place the original copy of the completed and signed CMS-29 form into the mail and put the letter into the outgoing mail or mailbox; (5) the costs for fringe labor and benefits; and (6) the costs for postage. We believe that it was important to revise the burden estimate to include these tasks in order to comply with 5 CFR 1320.3(b)(1).
To clarify our burden estimate in accordance with 5 CFR 1320.3, we have added an additional 25 minutes of time and costs to allow for the facility CEO to review and become familiar with the applicable statutory and regulatory language before signing the initial CMS-29 form. We have added this additional time and costs to our burden estimate because we believe it is necessary for the person signing the initial CMS-29 form to have knowledge of the statutory and regulatory law related to participation in the Medicare program and CMS provider agreements and we cannot assume that the signer has such familiarity with these statutes and regulations. However, we did not add this burden for the completion of the survey CMS-29 form.
We have also added 5 minutes of time and costs to allow for a Medical Secretary to photocopy the original completed and signed CMS-29 form and an additional 10 minutes of time for the Medical Secretary to mail the original completed and signed CMS-29 form to the State Survey Agency (i.e. – prepare mailing envelope with mailing and return addresses, affixing postage to envelope, fold the CMS-29 form and put into envelope, put letter into outgoing mail). Finally, we have allowed for fringe benefits in the amount of 100% of the total labor costs and added costs for postage.
Second, the increased time and cost burden is due, in part, to an increase in the number of RHCs since the last PRA package submission. The current number of RHCs thus far in calendar year 2018 is 4,243, which is a modest increase from 4,200 which is the number of RHCs which was stated in the previous PRA package. There was also a slight increase in the number of new RHCs. In the current burden estimate, we have used the 5 year average number of 210 new RHCs (5 year average number from 2013 to 2017). In the previous PRA package submission, we used a figure of approximately 200 new RHCs annually.
In addition, there’s a technical correction with regards to the individual responsible for completing and signing the CMS-29. The previous submission was calculated as the state agency surveyor being the responsible party for completing the form. However, the RHC must complete and sign the form. The state surveyor reviews the form prior to conducting a survey. This state’s cost is calculated under Federal Cost Estimates. Due to this technical corrections, there an increase in the burden from $3,750 to $15,592 (labor costs related to the completion of the initial CMS-29 form) or $49,843.50 (labor costs for completion of the survey CMS-29 form).
Perhaps, most importantly, one should not consider the cumulative burden associated with the completion of both the “initial” and “survey” CMS-29 forms as applying to an RHC at any point in time. While the total burden associated with the completion of the CMS-29 form, when looked at as a whole, looks rather high, it is important to remember that a given RHC will only be required to complete the CMS-29 form when they first open for business and then only every three years thereafter, when they are surveyed. Therefore, all RHCs will only incur either the burden for the completion of the “initial” CMS-29 form or they will incur the burden for completion of the burden for the “survey” CMS-29 form, but will never be required to incur the burden for both in any given year.
16. Publication and Tabulation Dates
There are no publication and tabulation dates associated with this collection.
17. OMB Expiration Date
CMS will display the expiration date on the forms.
18. Certification Statement
There are no exceptions to the certification statement.
C. Collection of Information Employing Statistical Methods
There are no statistical methods employed in this information collection.
1 This is the estimated cost incurred by the 10 CMS ROs for the printing and distribution of the CMS-29 forms.
2 https://www.bls.gov/oes/2016/may/oes193022.htm
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement for |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-20 |