Form CMS-359 Comprehensive Outpatient Rehab Facility Request Form

Department of Health & Human Services
Centers For Medicare & Medicaid Services

Form Approved
OMB No. 0938-0267

_______________________________________________________________________________________________________________________

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT
FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM
(CMS-359)

Name Of Facility:

Street Address:

I. Identifying
Information City, County, State:

Zip Code:

Telephone Number:
(RD2)

Request To Establish Eligibility In:
II. Eligibility

1. Medicare

Proprietary
III. Type of
Control

IV. Type of
Services
Provided
Responses:
1. Employees

2. Under
Arrangement

3. Independent
Contractor

2. Medicaid

Non-Profit

Church
Other

Medicare/Medicaid Provider Number:

3. Both

Government

(RD7)

(RD5)

(RD1)

State/County:

State/ Region:
(RD3)

Related Provider Number:

(RD4)

(RD6)

Does your organization currently participate in Medicare as a
provider of Outpatient Physical Therapy/Speech Pathology (e.g.,
Comprehensive Outpatient Rehabilitation Facility)?

Yes

If yes, list your Medicare Provider Number:

No

(RD8)

(RD9)

1. Physical Therapy

4. Psychological Services

2. Physician Services

5. Occupational Therapy

8. Orthotic/Prosthetic Services

3. Social Services

6. Respiratory Therapy

9. Nurses

7. Speech Pathology

NOTE: More

than one number NOTE: More than one number may be used for each block.
may be used for
each block.
Note: Blocks #1, #2, and either #3 or #4 must be completed for the facility to be eligible for participation.

Cms-359 / OMB Approval Expires XX/XX/20XX

(RD10)

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Department of Health & Human Services
Centers For Medicare & Medicaid Services

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT
FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM
(CMS-359)

Form Approved
OMB No. 0938-0267

Whoever knowingly and willfully makes, or causes to be made, a false statement or representation on this statement may be prosecuted under
applicable Federal or State law. In addition, knowingly and willfully failing to fully, and accurately disclose this requested information may result
in denial of a request to participate, or where the entity already participates, a termination of its agreement of contract with the State agency or
the Secretary as appropriate.
Signature of Authorized Official:

Title of Authorized Official:

Date Signed:

CMS-359 / OMB Approval Expires XX/XX/20XX

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Department of Health & Human Services
Centers For Medicare & Medicaid Services

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT
FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM
(CMS-359)

Form Approved
OMB No. 0938-0267

General Instructions for Completing Form CMS-359
Purpose of this form: The filing of this request for certification will initiate the process of obtaining a decision as to whether the Conditions
of Participation are (continue to be) met.

Instructions: Please answer all questions as of the current date. Return the form to the State Survey agency in the envelope provided; retain a
copy for your files. If a return envelope is not provided, the name and address of the State Survey agency may be obtained from the nearest
Social Security District Office.

Question I – Identifying Information
•
•
•

Insert the full name under which the CORF operates, its address and telephone number.
Medicare/Medicaid provider number - Leave blank on all initial certifications. On all re-certifications, insert the facility's six digit provider number.
State/County/Region code - Leave blank. The appropriate CMS Location will complete

Question II – Eligibility
•
•
•

All applicants are to check block #1 (Medicaid) because CORF services are covered only under the Medicare program.
Blocks #2 and #3 are for future use only.
Do not enter anything for related provider number. The State Survey agency will complete this section.

Question III – Type of Control
•
•
•

Check only one category.
Check the category that is most descriptive of the type of organization operating the facility.
Use the following as a guide:
o

o

Proprietary - For profit corporations.

Non-profit church - A church affiliated facility governed by a board of directors and financed by contributions and earnings.

CMS-359 / OMB Approval Expires XX/XX/20XX

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Department of Health & Human Services
Centers For Medicare & Medicaid Services

Form Approved
OMB No. 0938-0267

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT
FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM
(CMS-359)

General Instructions for Completing Form CMS-359
(Continued)

o
o

Non-profit other than church - A facility which is generally governed by a community-based board of directors and financed by contributions
and earnings.
Government - A facility primarily administered by the State, county, city or other local unit of government.

Question IV - Services Provided
•
•

•

Blocks #1, #2 and either #3 or #4 must be completed for the facility to be eligible for participation since these are mandatory services.
Please indicate in each block how services are provided, using the following figures:
1. Employees
2. Under Arrangement
3. Independent Contractor

These terms are defined below. Note that more than one figure may be used for each block.
o

o
o

Employee - An individual who is paid a salary per unit time of work (i.e., hourly, yearly) is covered under Social Security and
Workmen’s Compensation and accrues benefits (i.e., sick leave, vacation)

Under Arrangement - The facility has an agreement with an organization to use their personnel. The facility pays the organization
and not the individuals providing the services.

Independent Contractor - An individual who is paid a sum of money based upon services rendered or units of time. However,
the independent contractor is not covered under Social Security through the facility and does not accrue benefits. The individual
generally has a contract with the facility.

CMS-359 / OMB Approval Expires XX/XX/20XX

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Department of Health & Human Services
Centers For Medicare & Medicaid Services

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT
FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM
(CMS-359)

Form Approved
OMB No. 0938-0267

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-0267 (Expires
XX/XX/202X). This is required for to obtain Medicare participation. The time required to complete this information collection is
estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure****

Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA
Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns
regarding where to submit your documents, please contact Joy Webb at 410-786-1667.

CMS-359 / OMB Approval Expires XX/XX/20XX

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