Inpatient Rehabilitation Facility - Patient Assessment Instrument

Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities (CMS-10036)

⚠️ Notice: This information collection may be referencing outdated material.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
Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf Instruction
CMS-10036 IRF- PAI vesion 4.0 IRF-PAI Version 4.0 - Effective October 1 2020.pdf Form and Instruction
IRF-PAI Version 4.0 Change Table - Effective October 1, 2020.docx Change Table for Proposed IRF QRP New and Modified Items IC Document

Information Collection (IC) Details

IC Title:	Inpatient Rehabilitation Facility - Patient Assessment Instrument	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10036	IRF- PAI vesion 4.0	IRF-PAI Version 4.0 - Effective October 1 2020.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Inpatient Rehabilitation Facility - Patient Assessment Instrument	FR Citation: 71 FR 67143

Number of Respondents: 1,122	Number of Respondents for Small Entity: 194

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	411,081	7,740	403,341
Annual IC Time Burden (Hours)	704,747	607,329	97,418
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Change Table for Proposed IRF QRP New and Modified Items	IRF-PAI Version 4.0 Change Table - Effective October 1, 2020.docx	10/03/2019

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