Information Collection

Comprehensive Outpatient Rehabilitation Facility Eligibility & Survey Forms And Information Collection Requirements In 42 Cfr 488.56, 488.58, 488.60, 488.64, 488.66 And 405.262

IC 113295 under ICR 198410-0938-006 · OMB 0938-0267.

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Information Collection (IC) Details

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IC Title:	COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ELIGIBILITY & SURVEY FORMS AND INFORMATION COLLECTION REQUIREMENTS IN 42 CFR 488.56, 488.58, 488.60, 488.64, 488.66 AND 405.262	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-359	No	No
Form	360	No	No
Form	HCFA-R-55	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 54	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	46,929	46,929
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded

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