COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ELIGIBILITY AND SURVEY FORMS

ICR 199103-0938-014

OMB: 0938-0267

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0938-0267 199103-0938-014
Historical Active 199009-0938-002
HHS/CMS
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ELIGIBILITY AND SURVEY FORMS
No material or nonsubstantive change to a currently approved collection   No
Emergency 03/01/1991
Approved with change 03/01/1991
Retrieve Notice of Action (NOA) 03/01/1991
  Inventory as of this Action Requested Previously Approved
11/30/1993 11/30/1993 11/30/1993
162 0 162
526 0 526
0 0 0

IN ORDER TO PARTICIPATE IN THE MEDICARE/MEDICAID PROGRAM AS A CORF PROVIDERS MUST MEET FEDERAL CONDITIONS FOR PARTICIPATION. THE CERTIFICATION FORM IS NEEDED TO DETERMINE IF PROVIDERS MEET AT LEAST PRELIMINARY REQUIREMENTS. THE SURVEY FORM IS USED TO RECORD PROVIDER COMPLIANCE WITH THE INDIVIDUAL CONDITIONS AND REPORT IT TO HCFA.

None
None


No

1
IC Title Form No. Form Name
COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY ELIGIBILITY AND SURVEY FORMS HCFA-359, HCFA-360

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 162 162 0 0 0 0
Annual Time Burden (Hours) 526 526 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
03/01/1991


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