Information Collection

CORF Request for Certification Form - CMS-359

IC 209505 under ICR 201702-0938-019 · OMB 0938-1091.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1091 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10282 CORF Request for Certification Form - CMS-359 Form and Instruction
CMS-10282 CORF Request for Certification to Participate in the Med CMS-359.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CORF Request for Certification Form - CMS-359	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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-10282	CORF Request for Certification to Participate in the Medicare Program	CMS-359.pdf		No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-40	40
Annual IC Time Burden (Hours)	-10	10
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.