Question I: Identifying information
The full name under which the clinic operates, street address, city, county and state, ZIP code and phone, plus the owners' name and address if the clinic name does not identify them.
CMS-29
VERIFICATION OF CLINIC DATA ? RURAL HEALTH CLINIC PROGRAM
- Agency
- CMS
- Revision
- 06/2022
- Fillable fields
- 29
- Pages
- 3
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-29: Verification of Clinic Data, Rural Health Clinic Program
Form CMS-29 is the Verification of Clinic Data for the Rural Health Clinic Program from the Centers for Medicare & Medicaid Services (CMS), part of the U.S. Department of Health and Human Services. Its instructions say filing it is part of the process of obtaining a decision as to whether the rural health clinic conditions for certification are met. The form is returned to the State agency handling the certification process, and it is also completed when the State agency surveys a participating rural health clinic (RHC).
The form has four questions to be completed by the clinic: identifying information for each clinic site and its owners, medical direction, clinic personnel in full-time equivalents, and type of control, including whether the clinic is a provider-based entity of a hospital or critical access hospital. It ends with a certification signed by an authorized official.
The instructions say to answer all questions as of the current date and to leave the State/County and State Region boxes blank. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-29
Question II: Medical direction
The name and address of the physician or physicians responsible for providing medical direction for the clinic site.
Question III: Clinic personnel
Full-time equivalents for physicians, nurse practitioners, physician assistants and other staff, with the discipline named for other staff. Trainees and volunteers are excluded.
Question IV: Type of control
Profit or nonprofit, and individual, corporation, partnership or government (state, local or federal). The instructions say nonprofit status is based on IRS tax exemption under section 501 of the Internal Revenue Code.
Provider-based status
Whether the RHC is a provider-based entity to a hospital or critical access hospital (CAH), under 42 CFR 413.65, and if yes, the CMS Certification Number of the main provider.
Certification and signature
A statement that the information is true, correct and complete and that services will conform with Federal, State and local laws, followed by the authorized official's signature, title and date.
How to complete Form CMS-29
- 1
Use one form per clinic site
The instructions say a separate form is submitted for each permanent clinic site run by a central organization.
- 2
Fill in Questions I and II
Enter the clinic's operating name, address, phone and owners if needed, and the physicians responsible for medical direction. Leave the State/County and State Region boxes blank.
- 3
Count full-time equivalents
The instructions say to add the hours each category worked in the week ending before the week of filing, divide by the clinic's standard work week, and show any fraction as .00, .25, .50 or .75.
- 4
Check the type of control
Check one box in Question IV, answer the provider-based question, and give the hospital or CAH's CCN if the answer is yes.
- 5
Sign and return it
The authorized official signs and dates the form. The instructions say to return it to the State agency in the envelope provided and keep a copy for your files.
Why fill Form CMS-29 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what the instructions say
Where to send it
To the State agency handling the certification process, in the envelope provided. If no envelope is provided, the form says the State agency's name and address can be obtained from the CMS regional office.
Help and timing
The instructions say assistance in filling out the form is available from the State agency, and ask that returning the form not be delayed.
Staffing note
The instructions say that in addition to the physician, a nurse practitioner, physician assistant or certified nurse-midwife is required for clinic eligibility, shown in B and/or C of Question III.
Personnel definitions
The instructions define physician, nurse practitioner and physician assistant for this form by State licensing, certification or completed training programs.
Confidential information
The certification says trade secret, privileged or confidential information, or highly sensitive personal information, will be protected from release by CMS under 5 U.S.C. 552(b)(4) and (b)(6).
Time to complete
The form estimates an average of 10 minutes per response. It shows OMB No. 0938-0074.
Related forms
CMS-1561A
HEALTH INSURANCE BENEFIT AGREEMENT-RURAL HEALTH CLINIC
9 fields, 2 pages
CMS-855A
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1,236 fields, 72 pages
CMS-2567
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
22 fields, 5 pages
CMS-1539
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL
51 fields, 2 pages
Who uses Form CMS-29?
The form is for rural health clinics and the State agencies that survey them.
Official sources and the blank
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Questions about Form CMS-29
What is Form CMS-29 used for?
The instructions say filing 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. It is also completed when the State agency surveys a participating RHC.
Where do I send Form CMS-29?
The form says to return it to the State agency handling the certification process, in the envelope provided, and to keep a copy. Without an envelope, the CMS regional office can give the State agency's name and address.
Is one form enough for several clinic sites?
No. The instructions say that if a central organization operates more than one permanent clinic site, a separate form is submitted for each site.
How are full-time equivalents counted?
The instructions say to add the hours worked by each category in the week ending before the week of filing and divide by the hours in the clinic's standard work week, using quarter fractions only. Trainees and volunteers are excluded.
Which boxes does the clinic leave blank?
The instructions say not to complete the State/County and State Region boxes. On resurveys, the surveyor inserts the clinic's CMS Certification Number.
What happens to the form during a resurvey?
The instructions say the surveyor brings the form, a clinic representative completes, signs and dates it by the end of the onsite visit, and the surveyor reviews it and initials it after the signature.