Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381)

(CMS-381) Extension Locations of Medicare Approved Providers of Outpatient Physical Therapy and Speech-Language Pathology (OPT) Services

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0273 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-381 Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381) Form and Instruction
CMS-381 REQUEST FOR IDENTIFICATION OF OPT/OSP PROVIDER’S CMS form 381. 09.09.20.pdf Form and Instruction
CMS-381 REQUEST FOR IDENTIFICATION OF OPT/OSP PROVIDER’S CMS form 381. 09.09.20.pdf Form and Instruction
Change Crosswalk for CMS-381. 09.04.20.docx Crosswalk IC Document
Change Crosswalk for CMS-381. 09.04.20.docx Crosswalk IC Document

Information Collection (IC) Details

IC Title:	Identification of Extension Units of Outpatient Physical Therapy/Outpatient Speech Pathology Providers and Support Regs. (CMS-381)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 485.701-485.729

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-381	REQUEST FOR IDENTIFICATION OF OPT/OSP PROVIDER’S	CMS form 381. 09.09.20.pdf		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 443	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	443	-1,718	2,161
Annual IC Time Burden (Hours)	111	-429	540
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Change Crosswalk for CMS-381. 09.04.20.docx	01/14/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.