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⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-10036 Inpatient Rehabilitation Facility - Patient Assessment Instrument Form and Instruction
Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf Instruction
CMS-10036 IRF- PAI vesion 4.0 Final IRF-PAI Version 3.0 - Effective October 1 2019.pdf Form and Instruction

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
Form and Instruction	CMS-10036	IRF- PAI vesion 4.0	Final IRF-PAI Version 3.0 - Effective October 1 2019.pdf		Yes	Yes	Fillable Fileable
Instruction			Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.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	Previously Approved
Annual Number of Responses for this IC	411,081	411,081
Annual IC Time Burden (Hours)	704,747	704,747
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.