I. Identifying information
The full name under which the CORF operates, street address, city, county, state, ZIP code, telephone and Medicare/Medicaid provider number, with State/County and State/Region code boxes left blank.
CMS-359
CORF REPORT FOR CERTIFICATION TO PARTICIPATE IN MEDICARE
- Agency
- CMS
- Revision
- 2025-09-28
- Fillable fields
- 46
- Pages
- 5
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-359: CORF Report for Certification to Participate in the Medicare Program
Form CMS-359 is the Comprehensive Outpatient Rehabilitation Facility Report for Certification to Participate in the Medicare Program, from the Centers for Medicare & Medicaid Services. It is completed by a comprehensive outpatient rehabilitation facility (CORF). The instructions say filing this request for certification starts the process of deciding whether the Conditions of Participation are (continue to be) met, and that all questions are answered as of the current date.
The report has four questions: identifying information, eligibility, type of control and the services the facility provides, followed by a signature page for an authorized official. For each service, the facility shows whether it is provided by employees, under arrangement or by an independent contractor.
The instructions say to return the form to the State Survey agency in the envelope provided and keep a copy. The form carries OMB number 0938-0267 with an approval expiration of 09/30/2028. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-359
II. Eligibility
Request to establish eligibility in 1. Medicare, 2. Medicaid or 3. Both, and a related provider number that the State Survey agency completes.
III. Type of control
Proprietary, Non-Profit (Church or Other) or Government, and whether the organization currently participates in Medicare as a provider of Outpatient Physical Therapy/Speech Pathology, with its provider number if yes.
IV. Type of services provided
Nine blocks: Physical Therapy, Physician Services, Social Services, Psychological Services, Occupational Therapy, Respiratory Therapy, Speech Pathology, Orthotic/Prosthetic Services and Nurses.
Signature page
A statement on false statements and failure to disclose, then the signature and title of the authorized official and the date signed.
Instructions and definitions
Guidance for each question, definitions of the control types and of Employee, Under Arrangement and Independent Contractor, and the PRA disclosure statement.
Two pages of form are followed by three pages of instructions and the PRA statement.
How to fill out Form CMS-359
- 1
Enter identifying information
Enter the facility's full operating name, address and phone. Leave the provider number blank on an initial certification, or enter it on a recertification.
- 2
Mark eligibility
The instructions say all applicants check block #1, because CORF services are covered only under the Medicare program, and that blocks #2 and #3 are for future use only.
- 3
Choose the type of control
Check only one category, the one most descriptive of the organization operating the facility, using the definitions in the instructions.
- 4
Show how services are provided
In each service block, enter 1 for Employees, 2 for Under Arrangement or 3 for Independent Contractor. More than one number may be used for each block.
- 5
Sign the report
The authorized official signs page 2 and enters their title and the date signed.
- 6
Return it to the State Survey agency
The instructions say to return the form in the envelope provided and keep a copy. Without an envelope, the agency's name and address can be obtained from the nearest Social Security District Office.
Why fill Form CMS-359 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes and what the form says
Where to send it
To the State Survey agency in the envelope provided, keeping a copy. The CMS address in the PRA statement is for comments on the time estimate, not for the report.
Mandatory services
The form says Blocks #1, #2 and either #3 or #4 must be completed for the facility to be eligible for participation, since these are mandatory services.
False statements
The form says knowingly and willfully making a false statement may be prosecuted, and failing to fully and accurately disclose the information may result in denial of participation or termination of an existing agreement.
Time to complete
The PRA statement estimates an average of 30 minutes per response.
Questions about where to submit
The form lists Joy Webb at 410-786-1667 for questions or concerns about where to submit documents.
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CMS-855A
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CMS-1561
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CMS-2567
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CMS-417
HOSPICE REQUEST FOR CERTIFICATION IN MEDICARE
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Who uses Form CMS-359?
The form is for facilities, not for individual patients.
Official sources and the blank
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Questions about Form CMS-359
What is a CORF?
CORF stands for comprehensive outpatient rehabilitation facility, as the form's full title shows. Form CMS-359 is the report such a facility files for certification to participate in Medicare.
Where is Form CMS-359 sent?
The instructions say to return it to the State Survey agency in the envelope provided and keep a copy. If no envelope is provided, the agency's name and address can be obtained from the nearest Social Security District Office.
Which eligibility block does a CORF check?
The instructions say all applicants check block #1, because CORF services are covered only under the Medicare program. Blocks #2 and #3 are for future use only.
Which services does the form call mandatory?
The form says Blocks #1, #2 and either #3 or #4 must be completed for the facility to be eligible: Physical Therapy, Physician Services, and either Social Services or Psychological Services.
What do Employees, Under Arrangement and Independent Contractor mean?
The instructions define an employee as salaried with benefits, under arrangement as the facility paying an organization for its personnel, and an independent contractor as paid for services or time without benefits through the facility.
Is the provider number needed on a first certification?
No. The instructions say to leave it blank on all initial certifications and to insert the six digit provider number on re-certifications.