Request For Certification In The Medicare And-Or Medicaid Program To Provide Outpatient Physical Therapy {CMS-1856}

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 AND/OR SPEECH PATHOLOGY SERVICES REQUEST TO ESTABLISH ELIGIBILITY IN MEDICARE/MEDICAID PROVIDER NUMBER STATE/COUNTY STATE REGION RELATED PROVIDER NUMBER 1. MEDICARE 2. MEDICAID 3. BOTH R22 R1 R2 R3 R12 NAME OF ORGANIZATION I. IDENTIFYING INFORMATION CITY, COUNTY, AND STATE STREET ADDRESS ZIP CODE TELEPHONE NO. (INCLUDE AREA CODE) R6 II. SERVICES PROVIDED R18 1. PHYSICAL THERAPY 2. SPEECH PATHOLOGY 3. OCCUPATIONAL THERAPY 4. ALL 1. III. TYPE OF ORGANIZATION (CHECK ONE) R9 HOSPITAL SKILLED NURSING FACILITY HOME HEALTH AGENCY 4. 5. 6. REHABILITATION AGENCY PUBLIC CLINIC PRIVATE CLINIC 7. PUBLIC HEALTH AGENCY 2. 3. 1. VOLUNTARY NON-PROFIT OTHER THAN CHURCH VOLUNTARY NON-PROFIT CHURCH STATE GOVERNMENT 4. 5. 6. LOCAL GOVERNMENT COMBINATION GOVERNMENT & VOLUNTARY PROPRIETARY IV. TYPE OF CONTROL (CHECK ONE) R10 2. 3. NUMBER OF QUALIFIED PERSONNEL (FULL-TIME EQUIVALENTS) 1. TOTAL (2 & 3) V. PHYSICAL THERAPISTS R13 R14 R15 2. ON STAFF 3. BY ARRANGEMENT 1. TOTAL (2 & 3) VI. SPEECH PATHOLOGISTS R19 2. ON STAFF R20 3. BY ARRANGEMENT R21 1. TOTAL (2 & 3) VII. OCCUPATIONAL THERAPISTS R22 2. ON STAFF R23 3. BY ARRANGEMENT 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 American LegalNet, Inc. www.FormsWorkflow.com 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 Submission of this form will initiate the process of obtaining a decision as to whether the conditions of participation are met. Do not delay returning the form even though certain information is not now available. Assistance in completing the form is available from the State agency. Answer all questions as of the current date. Return the original and first two copies to the State agency in the envelope provided; retain the last copy for your files. If a return envelope is not provided, the name and address of the State agency may be obtained from the nearest Social Security office. Detailed instructions or definitions are given below for questions other than those considered self-explanatory. MEDICARE/MEDICAID PROVIDER NUMBER--Leave blank on all initial certifications. On all recertifications, insert the facility's assigned six-digit provider number. State/County Code and State Region--Leave blank. The Centers for Medicare & Medicaid Services Regional Office will complete. Related Provider Number--Complete this block when a facility is participating under more than one provider number, such as a facility having distinct parts or more than one level of care. The number in this block for each related provider will be the provider number of the highest level of care, e.g., a) If a hospital has a Distinct Part SNF, ICF and an independently-owned OPT Service, the Related Provider Number block on the application for each provider (including the hospital) will have the hospital provider number. b) If an OPT is SNF-based, the Related Provider Number block on both the SNF and the OPT applications will have the SNF provider number. NOTE: If a facility has both a participating and non-participating provider number, the related provider number on both applications will be the participating number. Question I--Insert the full name under which the organization operates. Question III--Definitions: Rehabilitation agency is an agency which provides an integrated multidisciplinary program designed to upgrade the physical function of handicapped, 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. 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. 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. Questions V and VI--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. A qualified physical therapist is a person who is lice