Form CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment I

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0842

INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT

Form CMS-10036 (01/06)

1

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT

Form CMS-10036 (01/06)

2

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT

Form CMS-10036 (01/06)

3