Updated: 3/2/2006
RHC Resources
Certification Materials
The following is a listing of links which provide tools to help start a rural health clinic.
RAC Online Link to Census RHC Data Maps, Poverty, and HPSA/MUA information
RHC Fact Sheet (A 2-page summary of the RHC program from CMS)
Starting a Rural Health Clinic - A How-To Manual published in 2004
RHC Chartbook from University of Maine published in 2003
Current Federal Register for 12/24/2003 with Final RHC regulations.
Licensure
- 42 CFR, Part 491 Subpart A
- CMS State Operations Manual
- Guidance to Surveyors - Appendix G
- Survey Report - CMS - 30
- Request for Establishment of Eligibility – CMS 29
- Health Insurance Benefit Agreement - CMS Form 1561A
- Fiscal Intermediary Choice Form
- Applicant Instructions (Florida)
- Health Facility Licensing and Compliance Division (Texas)General Information, Eligibility and Entitlement
Enrollment Information
Provider Enrollment Process for Certified Providers
Enrollment Section of the CMS Website
Federal Health Care Provider/Supplier Enrollment Form
Rural Health Clinic Enrollment
CMS 855 FORMS & CHECKLIST (PDF 79 KB)
- Electronic version or PDF version (1,234 KB) HealthCare Providers that will bill Medicare fiscal intermediaries (CMS 855A)
- Electronic version or PDF version (1,458 KB) HealthCare Providers that will bill Medicare carriers (CMS 855B)
- Electronic version or PDF version(781 KB) Individual Health Care Practitioners (CMS 855I)
- Electronic version or PDF version (310 KB) Individual Reassignment of Benefits (CMS 855R)
- Electronic version or PDF version (892 KB) DMEPOS Suppliers (CMS 855S)
ADDITIONAL FORMS
After completing the enrollment form, you can also download additional forms that often (and should) accompany the CMS 855 enrollment forms that will help facilitate other actions. Therefore prior to leaving our web site, we suggest you look at the following links to determine if they pertain to you. They include the following:
- Medicare authorization agreement for electronic funds transfers (Form CMS 588 - PDF File, 425 KB);
- Medicare Participating Physician or Supplier Agreement (Form CMS 460 - PDF File, 126 KB); and
- Electronic Data Interchange (EDI) Agreement - PDF File, 9 KB
Rural
Health Clinics must be located in a medically underserved area. The following is a link that takes you to
the HRSA website with the HPSA, MUA, and MUP listings:
Health
Professional Shortage Area Database
Database
Search for Health Professional Shortage Areas (HPSAs) by region, state, county,
designation status,
and type of service and more. Includes date of latest designation status. Sponsoring
organization: Bureau of Primary Health Care
Medically Underserved Area/Medically Underserved Population (MUA/MUP) Database
Preparing for the Inspection
If your clinic is located in a rural, medically underserved area and you have completed your State Application and 855 Forms; then it is time to prepare the RHC policy and procedure manual. This Microsoft Word file will help you prepare the policy and procedure manual.
Rural Health Clinic Policy and Procedure Manual
Annual Evaluations
Each year a Rural Health Clinic is required to complete an annual evaluation or program evaluation by a group of professionals. Healthcare Business Specialists conducts a number of these annual evaluations each year. To help you complete your annual evaluation we have included a template for you to use in completing the evaluation. If you would like for us to come out and conduct the evaluation; just let us know. Here is the Word file:
Annual Evaluation Report Template