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Revisions to CMS-381 - Identification of Extension Locations of Medicare Approved Providers of Outpatient Physical Therapy and Speech Pathology Services (CMS-381)

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
1	1	Cover Page/ Instructions Title of Form	Revise title of form	Revise the title on the 1st page of the CMS-381 form from: “Model Letter Requesting Identification Of Extension Locations” To: “Request For Identification Of OPT/OSP Primary & Extension Locations (Cms-381)”	The first 2 paragraphs of the existing version of the CMS-381 form are the text of a cover letter to the OPT/OSP provider. The 3rd paragraph contain instructions to the OPT/OSP provider for completion of the CMS-381 form. These paragraphs are essentially a cover letter to the OPT/OPS provider, in which the State Survey Agency (SA) requests that they complete and return the form. The 3rd paragraph contains the instructions for completing the form. The data collection questions are located in the middle of the existing version of the CMS-381 form. These questions are followed by an attestation statement and the PRA disclosure statement. The title on the existing version of the CMS-381 form is: ““Model Letter Requesting Identification Of Extension Locations” In the revised CMS-381 form, we have revised this title to: “Request For Identification Of OPT/OSP Primary & Extension Locations (Cms-381)” We made this change because, as only the first 2 paragraph of the existing version of the CMS-381 form contains the cover letter text, the existing title on the 1st page of the CMS-381 form is confusing and not applicable to all of the contents of this form. We believe that this is a non-substantive change that will impose no additional burden on OPT/OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
2	1	Cover Page/ Instructions 1st line	Modify the 1st line of the form. Revise the text of this section.	We have removed the word “Dear” and replaced it with the words “To:” We have removed the word “Administrator” from underneath the first line and replaced it with the words “(Name of OPT/OSP Facility Director)”	Using the word “Dear” is inappropriate in a business setting, as this is a form of endearment. We have added the word “To:” because it is more neutral. We removed the word “Administrator” from the name line so as to leave the space clear to add the name of the facility’s director and replaced it with the words ““(Name of OPT/OSP Facility Director)” directly underneath the name line. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
3	1	Cover Page/ Instructions After 1st line	Add a new line for the SA to state the name of OPT/OSP facility to which the cover letter and CMS-381 form is being sent.	Add a new line for the name of the OPT/OPS facility to which the CMS-381 form is being sent with the text “(Name of OPT/OSP Facility)” placed directly under this line.	In the existing version of the CMS-381 form, the only information at the top of the form to identify to whom the CMS-381 form is being sent, is the name of the facility Administrator. There is a text box further down, after the 3rd paragraph, for the name of the facility name, however, this text box is mixed in with text boxes which request the identifying information for the SA that is sending the form. We believe that it would be better to add the name and address for the facility to which the cover letter and CMS-381 form is being sent at the top of the form, to make it look more like a normal correspondence. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
4	1	Cover Page/ Instructions After 1st line	Add a new line for address of OPT/OSP facility	Add a line for the address of the OPT/OPS facility to which the CMS-381 form is being sent with the text “(Name of OPT/OSP Facility)” placed directly under this line.	In the existing version of the CMS-381 form, the address of the OPT/OPS provider to which the cover letter and CMS-381 form us being sent is not identified. As, many health care providers have multiple locations, we believe that it is important for the SA to identify the address of the OPT/OPS facility to which the cover letter/instructions and CMS-381 form is being sent. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
5	1	Cover Page/ Instructions Introductory Paragraph, 1st sentence of the 1st paragraph,	Revise the text of the 1st sentence of the 1st paragraph.	Modify the text of the 1st sentence of the 1st paragraph from the following: “Our records indicate that the facility below’; is approved in the Medicare program as an outpatient physical therapy/speech pathology provider (OPT/OSP).” to the following: “Our records indicate that your OPT/OSP facility is approved in the Medicare program as an outpatient physical therapy/speech pathology (OPT/OSP) provider.”	We made this changes because in the revised CMS-381 form, we have removed the text block stating the name of the facility to which the cover letter and CMS-381 form is being sent from below this paragraph to above the paragraph at the beginning of the form. The purpose of this change is to separate the facility name from the identifying information for the SA that is sending the form because we believe that this is confusing and looks unusual. We also moved the identifying information for the OPT/OPS facility to which the CMS-381 form is being sent to the top of a cover letter/instructions page of the form to make that page look more like a proper correspondence. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
6	1	Cover Page/ Instructions Introductory Paragraph, 2nd paragraph 2nd sentence	Modify the wording of the 1st sentence of the 1st paragraph of this form.	Modify the 2nd sentence of the 1st paragraph from the following: “Providers, in addition to rendering services on their already approved premises at times render services on the premises of other institutions (e.g., skilled nursing facilities) or on a premise owned/leased/rented by the OPT/OSP.” to the following: “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.”	We have revised the order of the words in this sentence by removing the word “Providers” at the beginning of the sentence and adding the words “OPT’OPS providers may also” in the middle of the sentence after the words “approved premises”. We made this change because we believe that the existing wording of this sentence is awkward. We further believe that the revised wording of this sentence reads better. In the existing version of the CMS-381 form, the language “render services on the premises” was used when referring to the 2 categories of extension locations. This is technically and grammatically incorrect because you cannot perform services “on” a premises. You can only perform services “at” a premise. We believe that the revised text of this sentence reads better and is more grammatically correct. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
7	1	Cover Page/ Instructions Introductory section, 3rd paragraph	Revise the 1st sentence of the 3rd paragraph. Revise the format of the 3rd paragraph.	We have modified the 3rd paragraph of the CMS-381 form from the following: “Below is a form for the purpose of identifying the extension locations of your OPT/OSP. Please complete this form and return it to the State agency listed below within30 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 agency immediately. If you have any questions or problems, please call the State agency.” To the following: “INSTRUCTIONS FOR COMPLETING FORM CMS-381 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 Survey Agency 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 Survey Agency listed below.”	In the existing version of the CMS-381 form, the instructions for completing the form are hidden in the 3rd paragraph of text, after the 1st sentence. In the revised version of the CMS-381 form, we have pulled out these instructions from the 3rd paragraph and made them a separate section labeled “Instructions for Completing Form CMS-381”. We have re-formatted each instruction as a separately bulleted sentence so that they are prominent and easy to locate. We made this change because we believe that the instructions for completing the form are extremely important to the OPT/OPS provider in understanding and completing the CMS-381 form. We have also reformatted the text of the 1st sentence of the 3rd paragraph from” “Below is a form for the purpose of identifying the extension locations of your OPT/OSP. To “We request that you use the form below to identify all of the extension locations used by your OPT/OSP Facility.” We have made this change because we believe that the sentence as revised sounds better with the reformatted version of the instruction set. We believe that these are non-substantive changes that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
8	1	Cover Page/ Instructions Top left hand text block which is located after the 3rd paragraph of text.	Revise the text contained in the top left hand text block which is located after the 3rd paragraph of text.	We have revised the text in the top left hand text block from: “STATE AGENCY NAME” To: “Name of State Survey Agency Representative Sending Notice:” We have relocated the existing text from this text box (as revised) to the upper right hand text block.	In the existing version of the CMS-381, the text blocks located directly under the 3rd paragraph of text are provided for the SA to fill in the following information: “State Agency Name”, “State Agency Address”, “Facility’s Name”, and “Signature of Authorized State Agency Individual.” We believe that the correct information that should be displayed in these text blocks and the logical order in which this information should be presented is as follows: (from left to right and top to bottom in 3 rows/2 columns of text blocks): Name Of State Survey Agency Staff Person Sending Notice: State Survey Agency Name: Address Of State Survey Agency Signature Of Authorized State Survey Agency Official: Date: In the existing CMS-381 form, the text in the top, left hand text block is “Name of State Agency.” In the revised version of the CMS-381 form, we have changed the text in the top left hand text box to “Name of State Survey Agency Representative Sending Notice.” We made this change because the existing version of the CMS-381 form does not require the SA to provide the name of the person who sent the notice to the OPT/OSP provider. We believe that it is important for notice to state the identity of the person at the State survey agency that sent the notice. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
9	1	Cover Page/ Instructions Top right hand text block after the 3rd paragraph of text.	Modify the text contained in the top right hand text block located after the 3rd paragraph of text	Change the text in the top right hand text block from: “STATE AGENCY ADDRESS” to: “State Survey Agency Name”	On the existing version of the CMS-381 form the top right hand text block contains the following text: “STATE AGENCY ADDRESS” We have modified the text of the top right hand text block from “STATE AGENCY ADDRESS” to: “State Survey Agency Name”. We made this change for several reasons. First, we believe that the correct information that should be displayed in these text blocks about the person and the State Survey Agency sending the cover letter/instructions and CMS-381 form to the OPT/OPS provider as well as the logical order in which this information should be presented is as follows: (from left to right and top to bottom in 3 rows/2 columns of text blocks): Name Of State Survey Agency Staff Person Sending Notice: State Survey Agency Name: Address Of State Survey Agency Signature Of Authorized State Survey Agency Official: Date: Therefore, we moved the text of “State Agency Name” from the upper left text block to the upper right hand text block. We have also revised the text “State Agency Name” by adding the word “Survey”. This makes the text in the upper right hand text block in the revised CMS-381 form “State Survey Agency Name”. We made this change because we believe that this is the correct and proper term to be used for this agency. We believe that this is a non-substantive changes that will impose no additional burden on OPT-OSP providers.

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
10	1	Cover Page/ Instructions Lower left hand text block after the 3rd paragraph of text (on existing version of the CMS-381 form).	Add a 3rd row of text blocks, which make the lower row of text blocks in the existing CMS-381 form a middle row. Modify the text contained in the lower left hand text block located after the 3rd paragraph of the existing version of the CMS-381 form.	Change the text in the lower left hand block from: “FACILITY NAME” to: “Address of State Survey Agency”	In the existing version of the CMS-381 form, the text in the lower left hand text block is “FACILITY NAME”. We have replaced the existing text in lower left hand text block from: “FACILITY NAME” to: “Address of State Survey Agency” We made this change for several reasons. First, we believe that the correct information that should be displayed in these text blocks about the person and the State Survey Agency sending the cover letter/instructions and CMS-381 form to the OPT/OPS provider as well as the logical order in which this information should be presented is as follows: (from left to right and top to bottom in 3 rows/2 columns of text blocks): Name Of State Survey Agency Staff Person Sending Notice: State Survey Agency Name: Address Of State Survey Agency Signature Of Authorized State Survey Agency Official: Date: Therefore, we removed the text of “Facility Name” from the lower left text and replaced it with “Address of State Survey Agency”. Second, we believe that information about the name of the facility to which the cover letter/instructions and CMS-381 form is being sent should not be mixed together with the information about the State Survey Agency that is sending this information. Therefore, in the revised CMS-381 form, we have removed the text of “FACILITY NAME” from the lower right hand text block and replaced it with “Address of State Survey Agency”. We believe that this change separates the information about the addressee of the cover letter (i.e. – the OPT/OPS provider to which the cover letter and CMS-381 form is being sent) at the top of the form, and leaves the information about the sender of the correspondence at the bottom of the letter like in typical correspondences. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
11	1	Cover Page/ Instructions Lower right hand text blocks after the 3rd paragraph of text.	Modify the text contained in the middle right hand text blocks located after the 3rd paragraph of text	Change the text in the middle lower right hand block from: “Signature of Authorized State Agency Individual” to: “Signature of State Survey Agency Representative Sending Notice”	In the existing version of the CMS-381, the bottom right hand text box contains the following text: “Signature of Authorized State Agency Individual” We have added a 3rd row of text blocs making the bottom row in the existing version of the CMS-381 form the middle row of text blocks in the revised version of the CMS-381 form. We have modified the text of the right hand, middle text block to “Signature of State Survey Agency Representative Sending Notice”. We made this change because we believe that existing text of ““Signature of Authorized State Agency Individual” is non-descriptive because it does not describe what this person is authorized for or why they signed this notice. Also, we have added the word “Survey” to the text in this text block. We made this change because we believe that the correct and proper title for this agency is “State Survey Agency” not “State Agency”. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
12	1	Cover Page/ Instructions Below 2nd row of text blocks	Add a 3rd row of text blocks. Add new text to the left hand lower text box.	Add a 3rd row of text blocks, with the following information in the bottom left hand text block: “Date of Notice”	The existing version of the CMS-381 form does not provide the date that the cover letter/instructions and CMS-381 is sent to the OPT/OPS provider. We believe that the date of the notice would be important information for an OPT/OPS provider that received this notice to have. Knowing the date that the notice would tell them when the 30 day period to complete the form began. To remedy this situation, we have added a 3rd row of text blocks consisting of 2 columns. We added the following text in the 3rd row, left hand text box: “Date of Notice” We believe that, while this is a new data field that has been added to the revised CMS-381 form, it is on the cover page/instructions portion of the form and is to be completed by the State Survey Agency staff, not the provider. Therefore, this change imposes no additional burden on OPT/OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
13	1	Cover Page/ Instructions Below 2nd row of text blocks	Add a 3rd row of text blocks. Add the text “Telephone Number of State Survey Agency Contact Person” to the lower, right hand text block	Add a new 3rd row of text blocks Add the following text to the lower right hand text box: “Telephone Number of State Survey Agency Representative”	The existing version of the CMS-381 form, in the last sentence of the 3rd paragraph, it states “If you have any questions or problems, please call the State agency”. However, this form does not provide a telephone number for a person at the State Survey Agency that the OPT/OSP provider can call if they have questions about the CMS-381 form. We believe that it is important that the OPT/OPS provider that received this notice to be provided with a telephone number for a person at the State Survey Agency they can call if they have any questions about the CMS-381 form. To remedy this situation, we have added a 3rd row consisting of 2 columns. We added the following text to the 3rd row, right hand text box ““Telephone Number of State Survey Agency Representative” We believe that, while this is a new data field that has been added to the revised CMS-381 form, it is on the cover page/instructions portion of the form and is to be completed by the State Survey Agency staff, not the provider. Therefore, this change imposes no additional burden on OPT/OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
14	1	Added new 1st and 2nd pages to the CMS-381 form	Add a new 1st and 2nd page for the actual data collection portion of the CMS-381 form	We have modified this form so that the 1st page of this form is a cover letter text and instructions. On the revised CMS-381 form, the 1st page (2nd page of the document) contains the data collection questions. The 2nd page of the revised CMS-381 form (3nd page of the document) contains the affirmation statement, name, signature, & date blocks and the PRA disclosure statement.	In the existing version of the CMS-381 form, a cover letter, the instructions, the data collection questions, an affirmation statement with signature and date blocks and the PRA disclosure statement are all squished onto 1 page, using 7 font text that is extremely small and difficult to read. There is no reason to restrict the text of the contents of 1 page. There is no page limit for such forms and no reason to squish such forms onto one page so that they are so jumbled together in such small font as to make them literally unreadable. Therefore, we revised the CMS-381 form so that the cover letter and instructions are on the 1st page, the data collection part of the form is on the 2nd page and the affirmation and PRA disclosure statements are on the 3rd page. We believe that these changes will not impose any additional burden on the OPT/OPS providers that are required to complete the CMS-381 form because this is a non-substantive change that is intended to make it easier to read, understand and complete the form. We believe that if anything, these changes will decrease the OPT/OSP provider’s burden associated with this form.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
15	1	New page 2, title to data collection section	Modify title to data collection section	We have modified the title for the data collection section of the form from: “IDENTIFICATION OF EXTENSION LOCATIONS OF OPT/OSP PROVIDERS” To: “IDENTIFICATION OF THE OPT/OPS PROVIDER’S PRIMARY & EXTENSION LOCATIONS”	We believe that this title is more accurate because the data collection section collects information about the OPT/OSP providers primary location as well as their extension locations. We also believe that the title reads better with the words “OPT/OSP Providers” in the middle of the sentence instead of at the end of the sentence. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
16	1	New page 2, Text of the 1st data collection question	Modify the text of the 1st data collection question Label this question as “A”	We have identified the 1st data collection question as “A” We have also modified the text of question A from: “Indicate the name, address and provider number of your approved outpatient physical therapy/speech pathology provider (OPT/OSP) primary site, and complete if applicable, section A, B and C.” to: “A. Indicate the name, address and provider number for your primary approved outpatient physical therapy/speech pathology provider (OPT/OSP) site.”	We have reworded this sentence slightly to make it read better. We have also removed the last part of the sentence that states “and complete if applicable, section A, B and C.” because we have re-labeled the sections in this form. Therefore, the removed language is no longer accurate. In the existing version of the CMS-381 form, this data collection question is not identified with a letter of number. Also, some of the questions in the form were identified with letters, but the assignment of identification letters does not occur until the 3rd question. We believe that the identification of only part of the questions is arbitrary and confusing. In the revised version of the CMS-381 form, we have identified all of the data collection questions with capital letters. We have identified this data collection question as “A” because it is the first data collection question. We believe it is important that all the data collection forms be identified, not only part of them. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
17	1	New page 2, Text of the 2nd data collection question	Modify the text of the 2nd data collection question Re-letter this question from “A” to “B”	Re-labeled the 2nd data collection question from “A” to “B” Add 2 additional rows to collect information about a total of 3 extension sites. Modify the text of question B from: “Where services are rendered off the above premises and on the premises of other institutions (including those owned and/or rented by the OPT/OSP), list the name and address of these institutions. If more space is needed, attach an additional sheet of paper. “ to: “B. Indicate the name, address, and provider number (if any) for any extension site where your OPT/OSP services are provided on the premises of an institution.”	We have reworded this sentence slightly to make it read better. We have also removed the last part of the sentence that states “and complete if applicable, section A, B and C.” because we have re-labeled the sections in this form. Therefore, the removed language is no longer accurate. We have also revised the text of this question to specify that these are extension sites to be specified in this response are those on the premises of an institution. We made this change because the cover letter text, it states that there are 2 types of extension locations for OPT/OSP providers. The locations include: An extension location on the premises of other institutions (e.g., skilled nursing facilities); or An extension location on a premise owned/leased/rented by the OPT/OSP. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
18	1	New page 2, Text of the new 3rd data collection question, which is labeled as “B”	Add a new data collection question to the CMS-381 form, which is labeled as “B” Add 3 answer spaces under the text of this question in which the OPT/OSP provider can provide their responses.	We have added the following new data collection question “C” to the CMS-381 form : “B. Indicate the name, address, and provider number (if any) for any extension sites that are owned, leased, or rented by the OPT/OSP, (other than the primary site) where OPT/OSP services are provided.” We have also added 3 spaces under this question for the OPT/OPS provider to fill in the name, address and Provider number for any extension locations that fall in this category	In the cover letter text, it states that there are 2 types of extension locations for OPT/OSP providers. The locations include: An extension location on the premises of other institutions (e.g., skilled nursing facilities); or An extension location on a premise owned/leased/rented by the OPT/OSP. The text of data collection question A in the existing version of the CMS-381 form does not make a distinction between these 2 types of extension sites. We added this new data collection question because we believe that it is important for the SA to know which category each of the OPT/OPS provider’s listed extension sites fall in. On the existing version of the CMS-381 form, there is only one question about extension sites but this question asks for information about both categories of extension sites. This is the 2nd data collection question. While this new data collection question, this question collects information about one category of extension site. We have revised the existing data collection question to collect information about the other category of extension sites. We made this change because we believe that it is important to collect separate information about each category of extension sites for the OPT/OPS provider. We do not believe that it would impose any additional burden on OPT/OSP providers to complete this additional question. We say this because they would still have to document information for each type of extension site, either on the existing version of the CMS-381 form in the 2nd question, or on the revised CMS-381 form in the new data collection question C. The OPT/OPS provider would just be documenting the information for their extension sites that “are owned, leased, or rented by the OPT/OSP, (other than the primary site) where OPT/OSP services are provided” in a different place on the form. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
19	1	New page 2, Question currently labeled as “B” (Re-labeled as “D”)	Re-letter the data collection question currently labeled as “B” and re-labeled as “D”. Revise the text of the question was slightly. Add an additional answer selection.	We have revised the text of this question from: “B. List the number of OPT/OSP services rendered from your primary site. _____OPT ______ OSP _______OOT” to: “D. List the type of OPT/OSP services rendered from your primary site. ____OPT __ OSP ___OOT Other: __________specify)(”	In the existing version of the CMS-381 form, only part of the questions are lettered and this lettering starts halfway down the form. We believe this is unusual and confusing. Because of this unusual labeling scheme, in the existing version of the CMS-381, this question is labeled as “B”, even though it is the 4th question. In the revised version of the CMS-381 form, we have labeled all of the questions with capital letter designations. We have also added a new data collection question. Therefore, this question would be labeled as “D”. We believe that labeling all the questions with consecutive letters starting with A will help OPT/OPS provider answer the questions in consecutive order and keep them straight in their mind. It will also help them to determine the difference between the questions that seem similar. We also changed the word “number” in the text of this question to the word “type”. We did this because this question is not asking for the OPT/OPS provider to provide a number for the services provided but to place a check mark by the type of services provided. Therefore, the use of the word “number” in this context is incorrect. We have added an additional response category of “Other _________ (specify)” to this question. We did this to allow OPT/OSP providers that provide more that the listed category of services. We have added this additional category because OPT/OSP (rehab) providers are often multidisciplinary services which may also provide social and vocational adjustment services. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
20	1	New page 2, Question previously labeled as “C” (Re-labeled as “E”)	Re-label this question as “D” Revise the text of the question. Add an additional answer selection.	We have revised the text of this question from: “C. List the number of OPT/OSP services rendered from the premises of any extension location(s). _____OPT ______ OSP _______OOT” to: “List the type of OPT/OSP services rendered from the premise of any extension location(s). ____OPT __ OSP ___OOT Other: __________specify)(”	In the existing version of the CMS-381 form, only part of the questions are lettered and this lettering starts halfway down the form. We believe this is unusual and confusing. Because of this unusual labeling scheme, in the existing version of the CMS-381, this question is labeled as “B”, even though it is the 4th question. In the revised version of the CMS-381 form, we have labeled all of the questions with capital letter designations. We have also added a new data collection question. Therefore, this question would be labeled as “D”. We believe that labeling all the questions with consecutive letters starting with A will help OPT/OPS provider answer the questions in consecutive order and keep them straight in their mind. It will also help them to determine the difference between the questions that seem similar. We also changed the word “number” in the text of this question to the word “type”. We did this because this question is not asking for the OPT/OPS provider to provide a number for the services provided but to place a check mark by the type of services provided. Therefore, the use of the word “number” in this context is incorrect. We have added an additional response category of “Other _________ (specify)” to this question. We did this to allow OPT/OSP providers that provide more that the listed category of services. We have added this additional category because OPT/OSP (rehab) providers are often multidisciplinary services which may also provide social and vocational adjustment services. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
21	1	New page 3, title to data collection section	Modify title to 2nd page of data collection section	We have modified the title for the data collection section of the form from: “IDENTIFICATION OF EXTENSION LOCATIONS OF OPT/OSP PROVIDERS” To: “IDENTIFICATION OF THE OPT/OPS PROVIDER’S PRIMARY & EXTENSION LOCATIONS”	We believe that this title is more accurate because the data collection section collects information about the OPT/OSP providers primary location as well as their extension locations. We also believe that the title reads better having the words “OPT/OSP Providers” in the middle of the sentence instead of at the end of the sentence. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
22	1	New page 3 Attestation statement language and signature, title and date line for person completing the CMS-381 form	Move the Attestation statement language and signature, title and date line for person completing the CMS-381 form to a new page 3 Revise the text of the attestation statement	We have moved the text of the attestation statement language and the signature, title and date blocks to a new 3rd page. We have revised the attestation statement language from the following: “Whoever knowingly and willfully makes or causes to be made a false statement may be prosecuted under applicable Federal or State laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested 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.” To: “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 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.”	In the existing version of the CMS-381 form, the cover letter, instructions, the 5 data collection questions, the affirmation statement, signature, name & date block and the PRA disclosure language are all cramped together on one page. A tiny text font of 7 is used in order to get all of this text on 1 page. This make the form extremely difficult to read, understand and complete by OPT/OPS providers. There is no page limits for such forms and no justifiable reason why the CMS-381 form is cramped together in such a manner. In the revised version of the CMS-381 form, we have used an 11 font for all text, placed the cover letter and instructions content on a cover page and made the CMS-381 form separate from this cover page. On the revised CMS-381 form, the data collection questions are located on page 1 and provided plenty of space for the OPT/OSP provider to provide their responses. There are spaces for OPT/OSP provider to provide information about each category of extension location(s). We do not anticipate that OPT/OSP providers would have more than 3 extension locations of each category. The affirmation statement, signature, name & date block and the PRA disclosure language have been re-located to a new page 2 of the revised CMS-381 form. We believe that the addition of a cover/instruction page and a 2nd page to the CMS-381 form as well as the division of the contents in this manner makes sense. We also believe that the CMS-381 form, as revised is neat and clean in appearance, pleasant to view, and easy to read and understand. We have revised the text of the affirmation statement because we believe that the text if the affirmation statement in the existing CMS-381 form is merely a statement of the penalties that occur from making a false statement. It does not require the person signing the form to affirm that the answers that they have provided are true and correct to the best of their knowledge information and belief and that they actually acknowledge the penalties for giving a false statement. The affirmation language in the revised CMS-381 form does actually require the person completing the form to affirm that the answers that they have provided are true and correct to the best of their knowledge information and belief and that they actually acknowledge the penalties for giving a false statement. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.
Issue #	Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
23	1	New Page 3 PRA Disclosure Statement	Move PRA disclosure statement language to new page 3	Move the PRA disclosure statement language to the new page 3.	In the existing version of the CMS-381 form, the cover letter, instructions, the 5 data collection questions, the affirmation statement, signature, name & date block and the PRA disclosure language are all cramped together on one page. A tiny text font of 7 is used in order to get all of this text on 1 page. This make the form extremely difficult to read, understand and complete by OPT/OPS providers. There is no page limits for such forms and no justifiable reason why the CMS-381 form is cramped together in such a manner. In the revised version of the CMS-381 form, we have used an 11 font for all text, placed the cover letter and instructions content on a cover page and made the CMS-381 form separate from this cover page. On the revised CMS-381 form, the data collection questions are located on page 1 and provided plenty of space for the OPT/OSP provider to provide their responses. There are spaces for OPT/OSP provider to provide information about each category of extension location(s). We do not anticipate that OPT/OSP providers would have more than 3 extension locations of each category. The affirmation statement, signature, name & date block and the PRA disclosure language have been re-located to a new page 2 of the revised CMS-381 form. We believe that the addition of a cover/instruction page and a 2nd page to the CMS-381 form as well as the division of the contents in this manner makes sense. We also believe that the CMS-381 form, as revised is neat and clean in appearance, pleasant to view, and easy to read and understand. We believe that this is a non-substantive change that will impose no additional burden on OPT-OSP providers.

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