Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...

(CMS-359/360) Comprehensive Outpatient Rehabilitation Facility (CORF) Certification and Survey Forms

Documents and Forms

Document Name Document Type
Form CMS-360 Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64... Form and Instruction
CMS-359 Comprehensive Outpatient Rehab Facility Request Form CMS-359.Revised.05.29.20.pdf Form and Instruction
CMS-359 Comprehensive Outpatient Rehab Facility Request Form CMS-359.Revised.05.29.20.pdf Form and Instruction
CMS-360 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY CMS-360. Updated. 05.29.20.pdf Form and Instruction
CMS-360 COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY CMS-360. Updated. 05.29.20.pdf Form and Instruction
CMS-359 Crosswalk 05.06.20.pdf CMS-359 crosswalk IC Document
CMS-359 Crosswalk 05.06.20.pdf CMS-359 crosswalk IC Document
CMS-360 Crosswalk 05.06.20.pdf CMS-360 crosswalk IC Document
CMS-360 Crosswalk 05.06.20.pdf CMS-360 crosswalk IC Document

Information Collection (IC) Details

IC Title:	Comprehensive Outpatient Rehabilitation Facility (CORF) Eligibility and Survey Forms and Information Collection Requirements in 42 CFR 485.56, 485.58, 485.60, 485.64...	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
Form and Instruction	CMS-359	Comprehensive Outpatient Rehab Facility Request Form	CMS-359.Revised.05.29.20.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-360	COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY SURVEY REPORT	CMS-360. Updated. 05.29.20.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	18	-32	50
Annual IC Time Burden (Hours)	76	-47	123
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-359 crosswalk	CMS-359 Crosswalk 05.06.20.pdf	09/10/2020
CMS-360 crosswalk	CMS-360 Crosswalk 05.06.20.pdf	09/10/2020

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