Information Collection

Review Choice Demonstration for Inpatient Rehabilitation Facility Services

IC 249216 under ICR 202507-0938-027 · OMB 0938-1420.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10765 Review Choice Demonstration for Inpatient Rehabilitation Facility Services	Form and Instruction
Form CMS-10765 Review Choice Demonstration for Inpatient Rehabilitation Facility Services Review Choice Demonstration for Inpatient Rehabilitation Facility Services	Form and Instruction
CMS-10765 Review Choice Demonstration for Inpatient Rehabilitation CMS-10765 - IRF Instrument.docx	Form and Instruction
CMS-10765 Review Choice Demonstration for Inpatient Rehabilitation CMS-10765 - IRF Instrument.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

CPI-10765

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 402(a)(1)(J) (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10765				Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 237,419

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	237,419	57,509	179,910
Annual IC Time Burden (Hours)	120,317	28,784	91,533
Annual IC Cost Burden (Dollars)	7,896,556	1,912,749	5,983,807

Documents for IC

table that charts IC Documents
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.

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