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

ICR 202106-0938-001

OMB: 0938-0074

Federal Form Document

Forms and Documents
ICR Details
0938-0074 202106-0938-001
Received in OIRA 201808-0938-008
(CMS-29) Request for Certification as Rural Health Clinic Form and Supporting Regulations
Extension without change of a currently approved collection   No
Regular 06/01/2021
  Requested Previously Approved
36 Months From Approved 09/30/2021
5,951 5,082
1,269 801
900 812

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
   Statute at Large: 17 Stat. 1875

Not associated with rulemaking

  86 FR 14926 05/19/2021
86 FR 29264 06/01/2021

  Total Request 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 5,951 5,082 0 0 869 0
Annual Time Burden (Hours) 1,269 801 0 -88 556 0
Annual Cost Burden (Dollars) 900 812 0 88 0 0
Miscellaneous Actions
As noted in the above table, the total burden hours have increased by 468 hours and the total burden costs have increased by $38,348.67. We attribute this increase to several factors. First, there has been an increase in the number of new RHCs and existing RHCs to be surveyed each year. In the previous PRA package it was estimated that there were 210 new RHCs per year and 1,414 RHCs surveyed per year. This equates to 1,624 responses per year. In the current PRA package, we have estimated that there are 290 new RHCs per year and an average of 1,597 exiting RHCs to be surveyed each year. This equates to 1,887 responses per year. This would also be an increase in the number of responses in the amount of 263. When factored into the burden calculation, this increase in the number of responses results in an increase in the total burden hours and burden costs.

Denise King 410 786-1013 [email protected]


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.

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