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⚠️ Notice: This information collection may be referencing outdated material.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
Final-Specifications-for-IRF-QRP-Quality-Measures-and-SPADEs.pdf Instruction
CMS-10036 IRF- PAI version 4.2 IRF-PAI-Version-4.2-Effective-10-01-24-v3_clean.docx Form and Instruction
CMS-10036 IRF- PAI version 4.2 IRF-PAI-Version-4.2-Effective-10-01-24-v3_clean.docx Form and Instruction
Crosswalk_IRF-PAI 4.1 to 4.2.doc.docx Crosswalk IC Document
Crosswalk_IRF-PAI 4.1 to 4.2.doc.docx Crosswalk IC Document
IRF-PAI-Version-4.2-Effective-10-01-24-v3_tc.docx Redline of IRF-PAI - Version 4.2 IC Document
IRF-PAI-Version-4.2-Effective-10-01-24-v3_tc.docx Redline of IRF-PAI - Version 4.2 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
Form and Instruction	CMS-10036	IRF- PAI version 4.2	IRF-PAI-Version-4.2-Effective-10-01-24-v3_clean.docx		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: 1,128	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	779,448	107,103	672,345
Annual IC Time Burden (Hours)	1,188,810	1,335	1,187,475
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk_IRF-PAI 4.1 to 4.2.doc.docx	04/27/2023
Redline of IRF-PAI - Version 4.2	IRF-PAI-Version-4.2-Effective-10-01-24-v3_tc.docx	04/27/2023

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