Review Choice Demonstration for Inpatient Rehabilitation Facility Services

Pre-Claim Review Demonstration for Inpatient Rehabilitation Facility Services (CMS-10765)

Documents and Forms

Document Name Document Type
Form CMS-10765 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

Information Collection (IC) Details

IC Title:	Review Choice Demonstration for Inpatient Rehabilitation Facility Services	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10765	Review Choice Demonstration for Inpatient Rehabilitation Facility Services	CMS-10765 - IRF Instrument.docx		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 %

	Requested	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

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.