Verification Of Clinic Data-Rural Health Clinic Program {CMS-29}

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 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 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 American LegalNet, Inc. www.FormsWorkFlow.com 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: (i) prepares registered nurses to perform an expanded role in the delivery of primary care; (ii) includes as least four months (in the aggregate) of classroom instruction and a component of supervised clinical practice; and (iii) awards a degree, diploma, or certificate to persons who successfully complete the program; or 3. 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 2. Has satisfactorily completed a program for preparing physician's assistants that: (i) was at least one academic year in length: (ii) 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 (iii) was accredited by the American Medical Association's Committee on Allied Health Education and Accreditation; or 3. 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