Form CMS-381 REQUEST FOR IDENTIFICATION OF OPT/OSP PROVIDER’S

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

REQUEST FOR IDENTIFICATION OF OPT/OSP PROVIDER’S
PRIMARY & EXTENSION LOCATIONS (CMS-381)

Form Approved
OMB NO. 0938-0273

To: ____________________________________________
(Name of OPT/OSP Facility Director)
___________________________________________
(Name of OPT/OSP Facility)
___________________________________________
(Address of OPT/OSP Facility)

Our records indicate that your OPT/OSP facility is approved in the Medicare program as an outpatient physical
therapy/speech pathology (OPT/OSP) provider. In addition to rendering services at their already approved premises,
OPT/OSP providers may also render services at the premises of other institutions (e.g., skilled nursing facilities) or at a
premise owned/leased/rented by the OPT/OSP. If the OPT/OSP bills the Medicare program for these services and renders
these services in an area within the institution set aside for rehabilitation care, these premises are considered extension
locations of the OPT/OSP. A patient’s home is not considered an extension location.

Extension locations are considered part of the OPT/OSP provider’s facility and are subject to the same approval policy as is
applicable to the OPT/OSP. In addition to meeting applicable sections of the conditions of participation for all outpatient
physical therapy/speech pathology providers, these extension locations fall under the OPT/OSP provider agreement and are
identified under the OPT/OSP provider number.
INSTRUCTIONS FOR COMPLETING FORM CMS-381

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We request that you use the form below to identify all of the extension locations used by your OPT/OSP. Facility.

Please complete this form and return it to the State SurveyAgency listed below within 30 days.

If at any time following completion of this form you plan to delete or add a service, or close or add an extension unit, please
notify the State Survey Agency immediately.

If you have any questions about or problems with completing the CMS-381 form, please call the State SurveyAgency listed
below.

Name Of State Survey Agency Representative Sending
Notice:

State Survey Agency Name:

Address Of State Survey Agency:

Signature Of State Survey Agency Representative Sending
Notice:

Date of Notice:

Telephone No. of State Survey Agency Representative:

Form CMS-381 / Approved / /2021

Cover Page / Instructions

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB NO. 0938-0273

REQUEST FOR IDENTIFICATION OF OPT/OSP PROVIDER’S
PRIMARY & EXTENSION LOCATIONS (CMS-381)

IDENTIFICATION OF THEOPT/ OSPPROVIDER’S PRIMARYANDEXTENSION LOCATIONS
A. Indicate the name, address and provider number for your primary approved outpatient physical therapy/speech

pathology provider (OPT/OSP) site.

NAME

PROVIDER NO.

ADDRESS

B.

TELEPHONE (Area Code)

Indicate the name, address, and provider number for any extension site where your OPT/OSP services are provided on
the premises of an institution.

NAME

ADDRESS

PROVIDER NO.

NAME

ADDRESS

PROVIDER NO.

NAME

ADDRESS

PROVIDER NO.

C. Indicate the name, address, and provider number for any extension sites that are owned, leased, or rented by your
OPT/OSP facility, (other than the primary site) where OPT/OSP services are provided.
NAME

ADDRESS

PROVIDER NO.

NAME

ADDRESS

PROVIDER NO.

NAME

ADDRESS

PROVIDER NO.

D. List the typeof OPT/OSP services rendered from your primary site.
OPT

OSP

OOT

Other: ____________________ (specify)

OPT

OSP

OOT

Other: ____________________ (specify)

E. List the type of OPT/OSP services rendered from the premises of all extension location(s).
F. Do your extension locations operate:(check one)

Form CMS-381 / Approved / /2021

_________ Full-time

__________ Part-time

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

REQUEST FOR IDENTIFICATION OF OPT/OSP PROVIDER’S
PRIMARY & EXTENSION LOCATIONS (CMS-381)

Form Approved
OMB NO. 0938-0273

AFFIRMATION STATEMENT

I hereby affirm that the above responses are truthful to the best of my knowledge, information and belief. I further
acknowledge that knowingly and willfully making or causing to be made a false statement may lead to prosecution
under applicable Federal or State laws. In addition, I acknowledge that knowingly and/or willfully failing to fully
and accurately disclose the information requested above may result in a denial of a request to participate, or
where the entity already participates, a termination of its agreement or contract with the State agency or the
Secretary, as appropriate.
SIGNATURE OFAUTHORIZED PERSON AT
OPT/OSP FACILITY

TITLE

DATE

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 0938-0273. Expiration Date: XX-XX-XXXX. The time required to complete this information
collection is estimated to average 15 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
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.
*****CMS Disclaimer***** 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
[email protected]

Form CMS-381 / Approved / /2021

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