Completion of the initial CMS-29 Form -new RHCs applying to participate in Medicare Program

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0074 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-29 Completion of the initial CMS-29 Form -new RHCs applying to participate in Medicare Program Form and Instruction
CMS-29 Verification of Clinic Data - Rural Health Clinic Progra CMS-29 form (08-17-2018).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Completion of the initial CMS-29 Form -new RHCs applying to participate in Medicare Program	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-29	Verification of Clinic Data - Rural Health Clinic Program	CMS-29 form (08-17-2018).pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 210	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	210	-690	900
Annual IC Time Burden (Hours)	70	-80	150
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.