Model Letter Requesting Identification Of Extension Units {CMS-381}

CMS-381 - 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. 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. For initial enrollment, the form must be submitted with the CMS-855 to the Medicare Administrative Contractor (MAC), and extension site requests should be included in Part III. For existing providers, the form should accompany the CMS-855 application for changes such as adding, closing, or converting extension sites. The MAC will review for enrollment criteria and forward the form for approval to the SA or Accrediting Organization (AO). When changing or converting extension sites, organizations should clearly explain the change in a cover letter to the MAC, SA, and AO. During resurvey, a State Agency surveyor may ask a facility representative to complete and sign the form during the onsite visit. www.FormsWorkflow.com