Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P

Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0842 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10036 Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P Form
irfpai-manual040104.pdf Instruction
CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment I CMS-10036.pdf Form

Information Collection (IC) Details

IC Title:	Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) data and Supporting Regulations in 42 CFR 412 Subpart P	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 412 Subpart P

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10036	Inpatient Rehabilitation Facility - Patient Assessment Instrument	CMS-10036.pdf		Yes	Yes	Paper Only
Instruction			irfpai-manual040104.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: : Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) System of Records, System No. 09-70-1518	FR Citation: 66 FR 56681

Number of Respondents: 160	Number of Respondents for Small Entity: 31

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	52,800	52,800
Annual IC Time Burden (Hours)	44,880	44,880
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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