- Form #
- CMS 29
- Form Title
- REQUEST TO ESTABLISH ELIGIBILITY TO PARTICIPATE IN HI FOR AGED/DISABLED TO PROVIDE RURAL HEALTH CLINIC SERVICES
- Revision Date
- 2011-11-01
- O.M.B. #
- 0938-0074
- O.M.B. Expiration Date
- 2015-04-30
- CMS Manual
- N/A
- Special Instructions
- N/A
