Form Cms-29 - Verification Of Clinic Data - Rural Health Clinic Program

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INSTRUCTIONS FOR COMPLETING THE VERIFICATION OF CLINIC DATA
RURAL HEALTH CLINIC PROGRAM
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
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 which 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.
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.)
Form CMS-29 (11/11) INSTRUCTIONS

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