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 (CMS-381)

As a result of recent certification process changes (Admin Info 22-02), CMS is revising the Form CMS-381 to streamline the certification processes for initial enrollment of an OPT/OSP. The Form CMS 381 is revised to reflect previous information on the Form CMS 1856 (which will be discontinued) and updated information for Medicare providers of Outpatient Physical Therapy and Speech Pathology Services (OPT) providing services at additional locations in addition to their Medicare approved primary site. These additional locations are called “extension locations” and must be reported by the provider and approved by CMS. Form CMS-381 provides a method for OPT providers to meet this reporting requirement. The revised form will be used for initial enrollment and requests for extension locations/sites.

The latest form for 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 (CMS-381) expires 2027-07-31 and is listed under ICR 202406-0938-004.