CMS-359 Comprehensive Outpatient Rehab Facility Request Form

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

Form Approved

OMB No. 0938-0267

INSTRUCTIONS FOR COMPLETING THE COMPREHENSIVE OUTPATIENT REHABILITATION

FACILITY REQUEST FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM

The filing of this request for certification will initiate the process of obtaining a decision as to whether the Conditions of Participation are (continue
to be) met.
GENERAL INSTRUCTIONS
Please answer all questions as of the current date. Return the form to the State agency in the envelope provided; retain a copy for your files. If a
return envelope is not provided, the name and address of the State agency may be obtained from the nearest Social Security District Office.
Question I. Identifying Information
Question IV. Services Provided
Insert the full name under which the CORF operates, its address and
telephone number.
Medicare/Medicaid provider number - Leave blank on all initial
certifications. On all recertifications, insert the facility's six digit provider
number.
State/County/Region code - Leave blank. CMS Regional Office will com­
plete.
Question II. Eligibility
All applicants are to check block #1 (Medicare). CORF services are
covered only under the Medicare program, hence, blocks #2 and #3
are for future use only. No entry for related provider number. State
agency will complete.
Question Ill. Type of Control
Check the one category that is most descriptive of the type of
organization operating the facility. Use the following as a guide:
Proprietary - For profit corporation.
Non-profit church - A church affiliated facility governed
by a board of directors and financed by contributions and
earnings.

Please indicate in each block how services are provided, using the
following figures:
1. Employees
2. Under Arrangement
3. Independent Contractor
These terms are defined below. Note that more than one figure may
be used for each block. Blocks #1, #2 and either #3 or #4 must be
completed for the facility to be eligible for participation since these are
mandatory services.
Employee - An individual who is paid a salary per unit time of work
(i.e., hourly, yearly), is covered under Social Security and Workmen's
Compensation and accrues benefits (i.e., sick leave, vacation).
Under Arrangement - The facility has an agreement with an organization
to use their personnel. The facility pays the organization and not the
individuals providing the services.
Independent Contractor - An individual who is paid a sum of money
based upon services rendered or units of time. However, the
independent contractor is not covered under Social Security through
the facility and does not accrue benefits. The individual generally has
a contract with the facility.

Non-profit other than church - A facility which is
generally governed by a community based board of
directors and financed by contributions and earnings.
Government - A facility primarily administered by the
State, county, city or other local unit of government.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-0267. The time required to complete this information collection is estimated to average 3 hours per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA
Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

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

Form Approved

OMB No. 0938-0267

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT

FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM

(Please read instructions on back before completing form)
STREET ADDRESS

I. IDENTIFYING NAME OF FACILITY
INFORMATION

MEDICARE/MEDICAID PROVIDER NUMBER
RD01

ZIP CODE

CITY, COUNTY, STATE

TELEPHONE NO. (Area Code)

STATE/COUNTY
RD02

II. ELIGIBILITY

REQUEST TO ESTABLISH ELIGIBILITY IN:

■
III. TYPE OF
CONTROL
(Check one)

1. MEDICARE

■

PROPRIETARY

RD04

RD03

RELATED PROVIDER NUMBER

2. MEDICAID

■

3. BOTH

NON-PROFIT

■

STATE REGION

■

CHURCH

■

OTHER

RD05

GOVERNMENT

RD06

Does your organization currently participate in Medicare as a provider of Outpatient
Physical Therapy/Speech Pathology (e.g., Rehabilitation Agency)?

■

YES

■

NO

RD08

If yes, list Provider No. ________________________________________________
RD07

IV. SERVICE PROVIDED:
Indicate in each block how services are
provided using the following numbers.
NOTE: More than one number may be used
for each block.
1. Employees
2. Under Arrangement
3. Independent Contractor
These terms are defined in the instructions
on the reverse side of this form.

RD09

■

1. PHYSICAL THERAPY

■

4. PSYCHOLOGICAL SERVICES

■

7. SPEECH PATHOLOGY

■

2. PHYSICIAN SERVICES

■

5. OCCUPATIONAL THERAPY

■

8. ORTHOTIC/PROSTHETIC SERVICES

■

3. SOCIAL SERVICES

■

6. RESPIRATORY THERAPY

■

9. NURSES

Blocks #1, #2, and either #3 or #4 must be completed for the facility to be eligible for participation.
RD10

Whoever knowingly and willfully makes or causes to be made a false statement or representation on this statement may be prosecuted under applicable Federal or
State law. In addition, knowingly and willfully failing to fully and accurately disclose this requested information may result in denial of a request to participate, or where
the entity already participates, a termination of its agreement of contract with the State agency or the Secretary as appropriate.
SIGNATURE OF AUTHORIZED OFFICIAL

TITLE

DATE

RD11

Form CMS-359 (XX/XX/XXXX)