(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations

(CMS-437) Psychiatric Unit Criteria Work Sheet and Supporting Regulations

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0358 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-437 (437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations Form and Instruction
CMS-437 Psychiatric Unit Criteria Worksheet CMS-437. Revised Instrument 05.03.18.docx Form and Instruction
Exhibit A - Change Crosswalk for CMS-437. 08.31.17.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	(437) Psychiatric Unit Criteria Work Sheet, Rehabilitation Unit Criteria Work Sheet and Rehabilitation Hospital Criteria Work Sheet, and Supporting Regulations	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 412.25-27

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-437	Psychiatric Unit Criteria Worksheet	CMS-437. Revised Instrument 05.03.18.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,616	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,616	2	1,614
Annual IC Time Burden (Hours)	1,212	808	404
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Exhibit A - Change Crosswalk for CMS-437. 08.31.17.docx	12/05/2017

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