Form Cms-1856 - Request For Certification In The Medicare And/or Medicaid Program To Provide Outpatient Physical Therapy And/or Speech Pathology Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0065

REQUEST FOR CERTIFICATION IN THE MEDICARE AND/OR MEDICAID PROGRAM

TO PROVIDE OUTPATIENT PHYSICAL THERAPY AND/OR SPEECH PATHOLOGY SERVICES

REQUEST TO ESTABLISH ELIGIBILITY IN

MEDICARE/MEDICAID

STATE/COUNTY

STATE REGION

RELATED PROVIDER NUMBER

PROVIDER NUMBER

1. MEDICARE

2. MEDICAID

3. BOTH

R22

R1

R2

R3

R12

NAME OF ORGANIZATION

STREET ADDRESS

I. IDENTIFYING INFORMATION

CITY, COUNTY, AND STATE

ZIP CODE

TELEPHONE NO.

(INCLUDE AREA CODE)

R6

II. SERVICES PROVIDED

1.

PHYSICAL THERAPY

2.

SPEECH PATHOLOGY

3.

OCCUPATIONAL THERAPY

4.

ALL

R18

1.

HOSPITAL

4.

REHABILITATION AGENCY

7.

PUBLIC HEALTH

AGENCY

III. TYPE OF ORGANIZATION

2.

SKILLED NURSING FACILITY

5.

PUBLIC CLINIC

(CHECK ONE)

3.

HOME HEALTH AGENCY

6.

PRIVATE CLINIC

R9

1.

VOLUNTARY NON-PROFIT OTHER THAN CHURCH

4.

LOCAL GOVERNMENT

IV. TYPE OF CONTROL

2.

VOLUNTARY NON-PROFIT CHURCH

5.

COMBINATION GOVERNMENT & VOLUNTARY

(CHECK ONE)

3.

STATE GOVERNMENT

6.

PROPRIETARY

R10

NUMBER OF QUALIFIED PERSONNEL (FULL-TIME EQUIVALENTS)

1. TOTAL (2 & 3)

2. ON STAFF

3. BY ARRANGEMENT

V. PHYSICAL THERAPISTS

R13

R14

R15

1. TOTAL (2 & 3)

2. ON STAFF

3. BY ARRANGEMENT

VI. SPEECH PATHOLOGISTS

R19

R20

R21

1. TOTAL (2 & 3)

2. ON STAFF

3. BY ARRANGEMENT

VII. OCCUPATIONAL THERAPISTS

R22

R23

R24

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

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 0938-0065. 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 21244-1850.

Form CMS-1856 (12/06) EF 12/2006