Form CMS-29 Verification of Clinic Data - Rural Health Clinic Progra

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO. 0938-0074

VERIFICATION OF CLINIC DATA - RURAL HEALTH CLINIC PROGRAM
CMS-29

CMS CERTIFICATION NO.

Each rural health clinic (RHC) site providing RHC services and seeking to participate in
the Medicare program must complete this form and return it to the State agency that is
handling the certification process. If a return envelope is not provided, the name and
address of the State agency may be obtained from the Center for Medicare & Medicaid
Services (CMS) regional office at http://www.cms.hhs.gov/RegionalOffices/. This form is
also to be completed when the State agency surveys a participating RHC.
NAME OF CLINIC

I. IDENTIFYING

INFORMATION

(TO BE COMPLETED BY EACH
CLINIC SITE)

(RH1)

STATE/COUNTY

(RH2)

STATE REGION

(RH3)

STREET ADDRESS

CITY, COUNTY AND STATE

ZIP CODE

TELEPHONE NO.
(Including Area Code)

NAME AND ADDRESS OF
CLINIC OWNER(S)

(RH4)

(RH5)

II. MEDICAL DIRECTION
III. CLINIC PERSONNEL
(FULL TIME
EQUIVALENTS)

(A) PHYSICIAN
(RH6)

IV. TYPE OF CONTROL
(check one)

1. Profit
(RH10)

(B) NURSE
PRACTITIONER

A. INDIVIDUAL

(C) PHYSICIAN
ASSISTANT
(RH7)

B. CORPORATION

(D) OTHER
(RH8)

C. PARTNERSHIP

(RH9)

D. GOVERNMENT

3. STATE _____

4. LOCAL _____

2. NonProfit

5. FEDERAL ____

Is the RHC a provider-based entity to a hospital or critical access hospital (CAH)?

Yes

○

No

(check one)

If yes, please indicate the CMS Certification Number of the hospital/CAH

○

(RH11)

(RH12)

I certify that this information is true, correct, and complete. I agree, if approval is granted, that all services rendered by the clinic shall be in
conformity with Federal, State, and local laws. I further understand that a violation of such laws will constitute grounds for withdrawal of
approval under the regulations. If any information within this application (or attachments thereto) constitutes a trade secret or privileged or
confidential information (as such terms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly
sensitive personal nature such that disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more
persons, then such information will be protected from release by CMS under 5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.

SIGNATURE OF AUTHORIZED OFFICIAL

Form CMS-29
OMB Approval Expires XX/XX/XXXX

TITLE

DATE

(RH13)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO. 0938-0074

____________________________________________________________________________________________________________________________________________

VERIFICATION OF CLINIC DATA - RURAL HEALTH CLINIC PROGRAM
CMS-29
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0074 (Expires XX/XX/202X). The time required to complete this information collection is
estimated to average 65 minutes per response, including the time to review instructions, search existing data
resources, to gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will
not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact Shonte Carter at (410) 786-3532.

Form CMS-29
OMB Approval Expires XX/XX/XXXX

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO. 0938-0074

____________________________________________________________________________________________________________________________________________

INSTRUCTIONS
FOR COMPLETING THE VERIFICATION OF CLINIC DATA
RURAL HEALTH CLINIC PROGRAM
(CMS-29 Form)
The filing of this verification of clinic data is part of the process of obtaining a decision as to whether the rural
health clinic conditions for certification are met.
Please do not delay returning the form. Assistance in filling out the form is available from the State agency.
GENERAL INSTRUCTIONS
Please answer all questions as of the current date.
Do not complete the categories identified as State/County or State Region. Return the form to the State agency in
the envelope provided; retain a copy for your files. If a return envelope is not provided, the name and address of the
State agency may be obtained from your Center for Medicare & Medicaid Services (CMS) regional office at
http://www.cms.hhs.gov/RegionalOffices/.
Detailed Instructions for Specific Questions
These instructions are designed to clarify certain questions on the form. Instructions are listed in question order for
easy reference. No instructions have been given for questions considered self-explanatory.
The Following to be Completed by the Clinic
Question I – Identifying Information
Insert the full name under which the clinic operates. A rural health clinic site is the location at which health services
are furnished. If a central organization operates more than one permanent clinic site, a separate Verification of
Clinic Data form for each rural health clinic site must be submitted. In these instances, the location of the health
clinic site, rather than of the central organization, will determine eligibility to participate. The applicant site must be
situated in a rural area that is designated as either an area with a shortage of personal health services or as a health
manpower shortage area because of its shortage of primary medical care manpower. If the name of the rural health
clinic site does not identify the owner(s), the name and address of the owner(s) are to be inserted in the space
provided; otherwise, that space is to be left blank.
Question II – Medical Direction
Insert the name and address of the physician(s) responsible for providing medical direction for the health clinic site.
Question III – Clinic Personnel
(A), (B), and (C) – Personnel are to be described in terms of full-time equivalents. To arrive at full-time
equivalents, add the total number of hours worked by personnel in each category in the week ending prior to the
week of filing the request and divide by the number of hours in the standard work week (as determined by the clinic
policies). If the result is not a whole number, express it as a quarter fraction only (e.g., .00, .25, .50, or .75).
Exclude all trainees and volunteers.

Form CMS-29
OMB Approval Expires XX/XX/XXXX

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO. 0938-0074

____________________________________________________________________________________________________________________________________________

INSTRUCTIONS
FOR COMPLETING THE VERIFICATION OF CLINIC DATA
RURAL HEALTH CLINIC PROGRAM
(CMS-29 Form)
In addition to the physician, a nurse practitioner, physician assistant or a certified nurse-midwife is required for
clinic eligibility and must be shown in B and/or C respectively.
(D) – Where other types of personnel are utilized (e.g., technicians, aides, etc.), the discipline, by name is to be
indicated in addition to the full-time equivalents.
Under (A), (B), and (C), include in the count only those personnel defined as follows:
Physician – A doctor of medicine or osteopathy legally authorized to practice medicine or surgery in the State in
which such function or action is performed. (A physician listed in II, above, should be included in this category for
purposes of determining full-time equivalents.)
Nurse practitioner – A registered professional nurse who is currently licensed to practice in the State, who meets
the State’s requirements governing the qualifications of nurse practitioners and who meets one of the following
conditions:
1.

Is currently certified as a primary care nurse practitioner by the American Nurses’ Association or by the
National Board of Pediatric Nurse Practitioners and Associates; or

2.

Has satisfactorily completed a formal one academic year educational program that:

3.

(i)

prepares registered nurses to perform an expanded role in the delivery of primary care; includes as least
four months (in the aggregate) of classroom instruction and a component of supervised clinical practice;
and

(ii)

awards a degree, diploma, or certificate to persons who successfully complete the program; or

Has successfully completed a formal educational program for preparing registered nurses to perform an
expanded role in the delivery of primary care that does not meet the requirements of paragraph (2) of this
section, and has been performing an expanded role in the delivery of primary care for a total of 12 months
during the 18-month period immediately preceding the effective date of this subpart.

Physician assistant – A person who meets the applicable State requirements governing the qualifications for
assistants to primary care physicians and who meets at least one of the following conditions:
1.

Is currently certified by the National Commission on Certification of Physician Assistants to assist primary
care physicians; or

Form CMS-29
OMB Approval Expires XX/XX/XXXX

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB NO. 0938-0074

____________________________________________________________________________________________________________________________________________

INSTRUCTIONS
FOR COMPLETING THE VERIFICATION OF CLINIC DATA
RURAL HEALTH CLINIC PROGRAM
(CMS-29 Form)

2.

Has satisfactorily completed a program for preparing physician’s assistants that:
(i)
(ii)
(iii)

3.

was at least one academic year in length:
consisted of supervised clinical practice and at least four months (in the aggregated) of
classroom instruction directed toward preparing students to deliver health care; and
was accredited by the American Medical Association’s Committee on Allied Health
Education and Accreditation; or

Has satisfactorily completed a formal educational program for preparing physician assistants that
does not meet the requirements of paragraph (2) of this section and has been assisting primary
care physicians for a total of 12 months during the 18-month period immediately preceding the
effective date of this subpart.

Question IV – Type of Control
Identify the rural health clinic in terms of its type of control by checking the appropriate column and row
under A, B, C or D. Nonprofit status is based on Internal Revenue Service tax exemption interpretation;
i.e., section 501 of the Internal Revenue Code of 1954.
Indicate if the rural health clinic site is or will be a provider-based entity to a hospital or critical access
hospital (CAH), in accordance with the provider-based rules located at 42 CFR 413.65. If yes, provide the
hospital or CAH’s CMS Certification Number (CCN) for the main provider to which the clinic is/will be
provider-based.
State Agency Responsibility
A function of the resurvey process is to obtain updated statistical information on organizations providing
rural health clinic services. At the time of resurvey, the surveyor will bring this form and request that a
representative of the organization complete, sign, and date it by the completion of the onsite visit. The
surveyor will review the form for completeness and accuracy and initial after the signature of the
organization’s representative. On all resurveys insert the clinic’s assigned CCN.

Form CMS-29
OMB Approval Expires XX/XX/XXXX

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