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

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. 03.16.21.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. 03.16.21.pdf		No		Printable Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 290	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 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	290	80	210
Annual IC Time Burden (Hours)	145	75	70
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.