Form Cms-359 - Corf Report For Certification To Participate In Medicare

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0267

INSTRUCTIONS FOR COMPLETING THE COMPREHENSIVE OUTPATIENT REHABILITATION

FACILITY REQUEST FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM

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.

GENERAL INSTRUCTIONS

Please answer all questions as of the current date. Return the form to the State 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 agency may be obtained from the nearest Social Security District Office.

Question I. Identifying Information

Question IV. Services Provided

Insert the full name under which the CORF operates, its address and

telephone number.

Please indicate in each block how services are provided, using the

following figures:

Medicare/Medicaid provider number - Leave blank on all initial

1. Employees

certifications. On all recertifications, insert the facility's six digit provider

2. Under Arrangement

number.

3. Independent Contractor

These terms are defined below. Note that more than one figure may

State/County/Region code - Leave blank. CMS Regional Office will com­

be used for each block. Blocks #1, #2 and either #3 or #4 must be

plete.

completed for the facility to be eligible for participation since these are

mandatory services.

Question II. Eligibility

Employee - An individual who is paid a salary per unit time of work

All applicants are to check block #1 (Medicare). CORF services are

(i.e., hourly, yearly), is covered under Social Security and Workmen's

covered only under the Medicare program, hence, blocks #2 and #3

Compensation and accrues benefits (i.e., sick leave, vacation).

are for future use only. No entry for related provider number. State

agency will complete.

Under Arrangement - The facility has an agreement with an organization

to use their personnel. The facility pays the organization and not the

Question Ill. Type of Control

individuals providing the services.

Check the one category that is most descriptive of the type of

Independent Contractor - An individual who is paid a sum of money

organization operating the facility. Use the following as a guide:

based upon services rendered or units of time. However, the

independent contractor is not covered under Social Security through

Proprietary - For profit corporation.

the facility and does not accrue benefits. The individual generally has

Non-profit church - A church affiliated facility governed

a contract with the facility.

by a board of directors and financed by contributions and

earnings.

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.

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. The time required to complete this information collection is estimated to average 3 hours 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 any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA

Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.