Cms-381 Request For Certification In The Medicare And/or Medicai

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

Form Approved
OMB No. 0938-0065

REQUEST FOR CERTIFICATION IN THE MEDICARE AND/OR MEDICAID PROGRAM
TO PROVIDE OUTPATIENT PHYSICAL THERAPY (OPT) AND/OR SPEECH PATHOLOGY
SERVICES (OSP)- INITIAL AND EXTENSION SITE REQUESTS
PART I- REQUEST INFORMATION
A. If this request is an initial request by an organization to be certified as a participating OPT/OSP, please complete the following and proceed to Part II:
REQUEST TO ESTABLISH ELIGIBILITY IN

MEDICARE

MEDICAID

BOTH

INITIAL REQUEST

YES

COUNTY

STATE

SEEKING DEEMED STATUS
NO

YES

NO

NAME OF ACCREDITING ORGANIZATION

B. If this request is to establish a new extension site, please complete the following and proceed to Part II:
CMS CERTIFICATION NUMBER OF
PRIMARY SITE

EXTENSION SITE
REQUEST
YES

NAME OF ACCREDITING ORGANIZATION (IF DEEMED):

NO

PART II- PRIMARY SITE WHERE THE OPT/OSP SERVICES ARE PROVIDED
LEGAL NAME OF ORGANIZATION
I. IDENTIFYING INFORMATION

DOING BUISNESS AS (DBA) NAME OF ORGANIZATION

CITY, COUNTY, AND STATE

III. SERVICES PROVIDED
(CHECK ALL THAT APPLY)

IV. TYPE OF ORGANIZATION

1.

PHYSICAL THERAPY

1.

HOSPITAL

2.
3.

STREET ADDRESS

ZIP CODE

2.

SPEECH PATHOLOGY

3.

4.

REHABILITATION

7.

SKILLED NURSING FACILITY

5.

PUBLIC CLINIC

HOME HEALTH AGENCY

6.

PRIVATE CLINIC

(CHECK ONE)

TELEPHONE NO. (INCLUDE AREA CODE)

OCCUPATIONAL THERAPY
PUBLIC HEALTH AGENCY

4.

ALL

PART II CONTINUED- PRIMARY SITE WHERE THE OPT/OSP SERVICES ARE PROVIDED

V. TYPE OF CONTROL
(CHECK ONE)

1.

VOLUNTARY NON-PROFIT OTHER THAN CHURCH

4.

LOCAL GOVERNMENT

2.

VOLUNTARY NON-PROFIT CHURCH

5.

COMBINATION GOVERNMENT & VOLUNTARY

3.

STATE GOVERNMENT

6.

PROPRIETARY

VI. HOURS OF OPERATION

Full-time

DOES YOUR PRIMARY LOCATION OPERATE: (check one)

Part-time

Full-Time Hours of Operation: _______________
IF PART-TIME, IDENTIFY DAYS AND HOURS OF OPERATION:
Hours of Operation: Monday (from) ________________ Tuesday (from) ________________ Wednesday (from) _______________ Thursday (from) _________________
(to) ________________

(to) ________________

(to) ________________

Friday (from) _______________

(to) ________________

(to) ________________

VII. QUALIFIED STAFF

PHYSICAL THERAPISTS

SPEECH PATHOLOGISTS

OCCUPATIONAL THERAPISTS

1. TOTAL (2 & 3)

2. ON STAFF

3. BY ARRANGEMENT

1. TOTAL (2 & 3)

2. ON STAFF

3. BY ARRANGEMENT

1. TOTAL (2 & 3)

2. ON STAFF

3. BY ARRANGEMENT

PART III- NEW EXTENSION SITE REQUEST WHERE THE OPT/OSP SERVICES ARE PROVIDED
LEGAL NAME OF ORGANIZATION
I. IDENTIFYING INFORMATION

DOING BUISNESS AS (DBA) NAME OF ORGANIZATION

CITY, COUNTY, AND STATE

STREET ADDRESS

ZIP CODE

TELEPHONE NO. (INCLUDE AREA CODE)
R6

II. SERVICES PROVIDED
(CHECK ALL THAT APPLY)

1.

PHYSICAL THERAPY

2.

SPEECH PATHOLOGY

3.

OCCUPATIONAL THERAPY

4.

ALL

PART III CONTINUED- NEW EXTENSION SITE WHERE THE OPT/OSP SERVICES ARE PROVIDED
III. HOURS OF OPERATION

WILL YOUR NEW EXTENSION LOCATION OPERATE: (check one)

Full-time

Part-time

Hours of Operation: _______________
IF PART-TIME, IDENTIFY DAYS AND HOURS OF OPERATION:
______ Monday

_______ Tuesday _______ Wednesday

_______Thursday

_______Friday

Hours of Operation: _______________

PART IV- EXISTING OR CLOSURES FOR EXTENSION SITES (Complete only for address changes and/or closures)
NAME OF ORGANIZATION

CLOSURE
ADDRESS CHANGE

EXTENSION IDENTIFICATION NUMBER

NEW ADDRESS, STATE, ZIP CODE

IF CLOSURE (DATE OF TERMINATION:
________________________/__________________________/_______________________

PART V- REQUEST TO CHANGE EXISTING EXTENSION SITE TO PRIMARY SITE (Complete only if your organization is already participating)
Is this a request to change an existing extension site to a primary site? Or is the existing primary location relocating and the current primary site requested to be the extension location?
YES

NO

If YES, COMPLETE BELOW:
I. PRIMARY LOCATION CONVERTING TO
EXTENSION SITE

II. EXTENSION SITE CONVERTING TO
PRIMARY SITE

NAME OF ORGANIZATION

PRIMARY SITE CMS CERTIFICATION NUMBER

ADDRESS

STATE/ZIP CODE

NAME OF ORGANIZATION

EXISTING EXTENSION IDENTIFICATION NUMBER

ADDRESS

STATE/ZIP CODE

PART VI- EXISTING EXTENSION SITES (Complete only if your organization is already participating)
I. LOCATION #1

II. LOCATION #2

III. LOCATION #3

IV. LOCATION #4

NAME OF ORGANIZATION

EXTENSION IDENTIFICATION NUMBER

ADDRESS

STATE/ZIP CODE

NAME OF ORGANIZATION

EXTENSION IDENTIFICATION NUMBER

ADDRESS

STATE/ZIP CODE

NAME OF ORGANIZATION

EXTENSION IDENTIFICATION NUMBER

ADDRESS

STATE/ZIP CODE

NAME OF ORGANIZATION

EXTENSION IDENTIFICATION NUMBER

ADDRESS

STATE/ZIP CODE

For additional extension sites, please attach Part VII addendum.
PART VII- LEGAL CONTACT INFORMATION
PRIMARY POINT OF CONTACT AT ORGANIZATION:
NAME:

TITLE/POSITION:

EMAIL:

TELEPHONE:

WHOEVER KNOWINGLY AND WILLINGLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT MAY BE PROSECUTED UNDER APPLICABLE
FEDERAL OR STATE LAWS. IN ADDITION, KNOWING AND WILLFULLY FAILING TO FULLY AND ACCURATELY DISCLOSE THIS INFORMATION REQUESTED 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
R17

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Form CMS-381 (Updated 2023)

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

Form Approved
OMB No. 0938-0065

INSTRUCTIONS FOR THE COMPLETION OF THE
REQUEST TO ESTABLISH ELIGIBILITY IN THE MEDICARE AND/OR MEDICAID PROGRAM
TO PROVIDE OUTPATIENT PHYSICAL THERAPY AND/OR
SPEECH PATHOLOGY SERVICES

INSTRUCTIONS FOR COMPLETING FORM CMS-381
General Instructions
• All new prospective organizations wishing to participate as an OPT/OSP provider in the Medicare
program and existing Medicare-certified OPTs requesting extension location requests must complete
Form CMS-381. Answer all questions as of the current date of the request. Part VII is required for all
submissions.
• The requesting organization must identify the primary site and any extension locations for the
facility.
• If your organization is uncertain about how to complete some of the fields, contact your State Survey
Agency (SA).
• For multiple extension site requests, each extension site(s) must be listed in Part III of the form. If
necessary, an additional document may be provided as long as the information in Part III is included
for each extension site.
• If an organization is requesting multiple extension sites at the same time, the organization is not
required to submit a CMS-855 for every location. One CMS-855 and this form will suffice. Follow the
instructions below.
NOTE: If an organization has submitted a CMS-855 to the MAC and submits an additional request within
90 days, please note that processing delays could occur as the MAC will be required to complete the first
requested change prior to starting the second request.

For Initial Enrollment:
• Please complete this form and include this form in the application submission of the CMS-855 to the
Medicare Administrative Contractor (MAC). (Part I, A; Part II)
• If the organization is submitting an extension site request in addition to the initial enrollment and
certification of the primary site location, please complete Part III in addition to Part I. A.
• The MAC will review for enrollment criteria and submit this form in addition to their recommendation
for approval to the State Agency (SA) and Accrediting Organization (AO) (if applicable).
• You may also copy the SA or AO in your request to the MAC. Contact information may be found at
https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc.

For Existing Medicare-participating OPT/OSP:
• Please complete this form and include it with the CMS-855 application submission to the Medicare
Administrative Contractor (MAC) for any changes following the guidance below.
• The MAC will review for enrollment criteria and submit this form in addition to their recommendation
for approval to the State Agency (SA) and Accrediting Organization (AO) (if applicable).
• You may also copy the SA or AO in your request to the MAC. Contact information may be found at
https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc.
• Request to add new Extension Site: Please complete this form any time your OPT is requesting a new
extension site or changing/removing an extension site. (Part I.A- Select “No” for initial request;
Complete Part I.B through Part III)
• Request to Close an Existing Extension Site or Update Address of an Existing Extension Site: (Part
I.A- Select “No” for initial request; Complete Part I.B through Part II and Part IV)
• Request to Convert an Existing Extension Site to the Primary Site, or Primary Site to an Extension
Site: If your organization is relocating its primary site to an extension location, please complete (Part
I.A- Select “No” for initial request; Complete Part I.B through Part II and Part V). It is recommended that
organizations clearly identify whether the organization is making a change to a primary site and an
extension site in a cover letter submitted to the MAC, SA and AO (if applicable). Extension sites have
specific identifiers within the CMS Certification Number (CCN). In the event of conversions, the primary
site CCN and extension site identifiers will need to be adjusted.
• Completing the Request at Resurvey: The SA Surveyor (non-deemed) will bring this form to any
resurvey and either request that a facility representative complete, sign, date, and return it at the
completion of the onsite visit, at which time the surveyor will review it for completeness and accuracy;
or the surveyor may complete the form and have the facility representative review and sign it.

Additional Guidance - Detailed instructions or definitions are given below for questions other than those
considered self-explanatory.
• CMS CERTIFICATION NUMBER—Leave blank on all initial certifications. On all recertifications,
insert the facility's assigned six-digit provider number.
• EXTENSION IDENTIFICATION NUMBER—Leave blank on all initial certifications for extension
locations. Insert extension identification numbers for all CMS-approved extension locations.
• County—Leave blank if not known.
• Name of Accrediting Organization- only insert if requesting deemed status or if already accredited.
List of CMS-approved AOs may be found https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertificationGenInfo/Downloads/Accrediting-Organization-Contacts-forProspective-Clients-.pdf
• Type of Organization:
o Hospital- self explanatory
o Skilled Nursing Facility- self explanatory
o Home Health Agency- self explanatory
o Rehabilitation agency is an agency which provides an integrated multidisciplinary program
designed to upgrade the physical function of disabled individuals by bringing together as a team
specialized rehabilitation personnel. At a minimum, it must provide physical therapy or speech
pathology services, and a rehabilitation program which, in addition to physical therapy or
speech pathology services, includes social or vocational adjustment services.
o Clinic is a facility established primarily for providing outpatient physician's services. It must
meet the following test of physician participation: (1) The medical services of the clinic are
provided by a group of physicians, i.e., more than two, practicing medicine together, and (2) a
physician is present in the clinic at all times to perform medical (rather than administrative)
services.
o Public Health Agency is an official agency established by a State or local government, the
primary function of which is to maintain the health of the population served by performing
environmental health services, preventive medical services, and, in certain cases, therapeutic
services.
• Qualified Staff (refer to § 485.705 Personnel qualifications).—To determine full-time
equivalents, add the total number of hours worked by the appropriate professionals in the week
ending prior to the week of filing the request and divide by the number of hours in the standard
work week. If the result is not a whole number, express it as a quarter fraction (e.g., .00, .25, .50,
.75). Include only qualified physical therapists and qualified speech pathologists.
o A qualified physical therapist is a person who is licensed as a physical therapist by the State in
which practicing and (1) has graduated from a physical therapy curriculum approved by the
American Physical Therapy Association or by the Council on Medical Education and Hospitals of
the American Medical Association, or jointly by the Council on Medical Education and Hospitals
of the American Medical Association and the American Physical Therapy Association; or (2)
prior to January 1, 1966: (a) was admitted to membership by the American Physical Therapy
Association; or (b) was admitted to registration by the American Registry of Physical
Therapists; or (c) has graduated from a physical therapy curriculum in a 4-year college or
university approved by a State department of education; or (3) has 2 years of appropriate
experience as a physical therapist and has achieved a satisfactory grade on a proficiency
examination approved by the Secretary, except that such determinations of proficiency shall not
apply with respect to persons initially licensed by a State or seeking qualification as a physical
therapist after December 31, 1977; or (4) was licensed or registered prior to January 1, 1966,
and prior to January 1, 1970, had 15 years of full-time experience in the treatment of illness or
injury through the practice of physical therapy in which services were rendered under the
order and direction of attending and referring physicians; or (5) if trained outside the United
States: (a) was graduated since 1928 from a physical therapy curriculum approved in the
country in which the curriculum was located and in which there is a member organization of
the World Confederation for Physical Therapy; (b) meets the requirements for membership in a
member organization of the World Confederation for Physical Therapy; (c) has 1 year of
experience under the supervision of an active member of the American Physical Therapy
Association; and (d) has successfully completed a qualifying examination as prescribed by the
American Physical Therapy Association.
o A qualified speech pathologist is a person who is licensed, if applicable, by the State in which
practicing: (1) is eligible for a certificate of clinical competence in speech pathology granted by the
American Speech and Hearing Association under its requirements in effect on January 17, 1974; or
(2) meets the educational requirements for certification, and is in the process of accumulating
the supervised experience required for certification.