Form Cms-381 - Model Letter Requesting Identification Of Extension Locations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB NO. 09380273

MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS

Dear

(Administrator)

Our records indicate that the facility below is approved in the Medicare program as an outpatient physical therapy/speech pathology provider (OPT/OSP).

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. 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 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.

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

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 agency

immediately. If you have any questions or problems, please call the State agency.

STATE AGENCY NAME

STATE AGENCY ADDRESS

FACILITY NAME

SIGNATURE OF AUTHORIZED STATE AGENCY INDIVIDUAL

IDENTIFICATION OF EXTENSION LOCATIONS OF OPT/OSP PROVIDERS

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.

NAME

PROVIDER NO.

ADDRESS

TELEPHONE (Area Code)

A. 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.

NAME

ADDRESS

NAME

ADDRESS

NAME

ADDRESS

B. List the number of OPT/OSP services rendered from your primary site.

_________

OPT

_________ OSP

_________ OOT

List the number of OPT/OSP services rendered from the premises of any extension location(s).

_________

OPT

_________ OSP

_________ OOT

C. Do your extension locations operate: (check one)

_________Fulltime

________Parttime

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.

SIGNATURE OF AUTHORIZED PERSON

TITLE

DATE

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 09380273. 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 212441850.

Form CMS381 (12/05) EF 06/2006