RIF Request Packet

Use Agreement (DUA) Limited Data Set (LDS) Forms Research Identifiable Files (FIF) Forms (CMS-R-235)

Documents and Forms

Document Name Document Type
Form CMS-R-235 RIF Request Packet Form and Instruction
CMS-R-235 RIF Request Application Attachment A - RIF Request Application .docx Form and Instruction
CMS-R-235 State Agency Supplement 06State-Agency-Supplement-final.pdf Form and Instruction
CMS-R-235 Innovator Supplement 05Innovator-Supplement-final.pdf Form and Instruction
CMS-R-235 Collaborator Supplement 04Collaborator-Supplement-final.pdf Form and Instruction
CMS-R-235 Key Personnel Supplement 03Key-Personnel-final.pdf Form and Instruction
CMS-R-235 Amendment Request Form 08RIF-Amendment-final-508.docx Form and Instruction
CMS-R-235 RIF Extenstion Request Form RIF Extenstion Request Form.docx Form and Instruction
CMS-R-235 RIF DUA Signature Addendum RIF DUA Signature Addendum.docx Form and Instruction
Attachment A - RIF Application REDLINE.pdf Track Change - RIF Application IC Document
RIF-Amendment REDLINE.pdf Track Change - RIF Amendment IC Document
RIF Amendment_JobAid.pdf RIF Amendment_JobAid IC Document
RIF Attachment A_JobAid.pdf RIF Application_JobAid IC Document
RIF Extension Request_JobAid.pdf RIF Extension Request_JobAid IC Document
RIF Signature Addendum_JobAid.pdf RIF Signature Addendum_JobAid IC Document
Form Fields .docx IT system - Data collection fields IC Document

Information Collection (IC) Details

IC Title:	RIF Request Packet	Agency IC Tracking Number:	CMS-R-235

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-R-235	RIF Request Application	Attachment A - RIF Request Application .docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	State Agency Supplement	06State-Agency-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Innovator Supplement	05Innovator-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Collaborator Supplement	04Collaborator-Supplement-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Key Personnel Supplement	03Key-Personnel-final.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	Amendment Request Form	08RIF-Amendment-final-508.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	RIF Extenstion Request Form	RIF Extenstion Request Form.docx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-R-235	RIF DUA Signature Addendum	RIF DUA Signature Addendum.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,455	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,455	750	2,705
Annual IC Time Burden (Hours)	1,624	375	1,249
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change - RIF Application	Attachment A - RIF Application REDLINE.pdf	05/27/2025
Track Change - RIF Amendment	RIF-Amendment REDLINE.pdf	05/27/2025
RIF Amendment_JobAid	RIF Amendment_JobAid.pdf	05/27/2025
RIF Application_JobAid	RIF Attachment A_JobAid.pdf	05/27/2025
RIF Extension Request_JobAid	RIF Extension Request_JobAid.pdf	05/27/2025
RIF Signature Addendum_JobAid	RIF Signature Addendum_JobAid.pdf	05/27/2025
IT system - Data collection fields	Form Fields .docx	05/29/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.