Form Cms-359 - Corf Report For Certification To Participate In Medicare (Page 2 of 2) in pdf

Form Cms-359 - Corf Report For Certification To Participate In Medicare Page 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0267

COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY REPORT

FOR CERTIFICATION TO PARTICIPATE IN THE MEDICARE PROGRAM

(Please read instructions on back before completing form)

NAME OF FACILITY

STREET ADDRESS

MEDICARE/MEDICAID PROVIDER NUMBER

I. IDENTIFYING

INFORMATION

RD01

ZIP CODE

TELEPHONE NO. (Area Code)

STATE/COUNTY

STATE REGION

CITY, COUNTY, STATE

RD02

RD03

RD04

REQUEST TO ESTABLISH ELIGIBILITY IN:

RELATED PROVIDER NUMBER

II. ELIGIBILITY

MEDICARE

2. MEDICAID

3. BOTH

RD05

RD06

PROPRIETARY

NON-PROFIT

GOVERNMENT

Does your organization currently participate in Medicare as a provider of Outpatient

III. TYPE OF

Physical Therapy/Speech Pathology (e.g., Rehabilitation Agency)?

CONTROL

CHURCH

(Check one)

YES

RD08

OTHER

If yes, list Provider No. ________________________________________________

RD07

RD09

IV. SERVICE PROVIDED:

Indicate in each block how services are

1. PHYSICAL THERAPY

4. PSYCHOLOGICAL SERVICES

7. SPEECH PATHOLOGY

provided using the following numbers.

NOTE: More than one number may be used

for each block.

2. PHYSICIAN SERVICES

5. OCCUPATIONAL THERAPY

8. ORTHOTIC/PROSTHETIC SERVICES

1. Employees

2. Under Arrangement

3. Independent Contractor

These terms are defined in the instructions

3. SOCIAL SERVICES

6. RESPIRATORY THERAPY

9. NURSES

on the reverse side of this form.

Blocks #1, #2, and either #3 or #4 must be completed for the facility to be eligible for participation.

RD10

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

DATE

RD11

Form CMS-359 (07/03)