CMS-381
MODEL LETTER REQUESTING IDENTIFICATION OF EXTENSION LOCATIONS
Form CMS-381 is listed on the CMS forms page as the Model Letter Requesting Identification of Extension Locations. The form itself is titled 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, from the Centers for Medicare & Medicaid Services (CMS).
Its instructions say it is completed by new prospective organizations wishing to participate as an OPT/OSP provider in Medicare and by existing Medicare-certified OPTs requesting extension locations. It goes with the CMS-855 application to the Medicare Administrative Contractor (MAC), which reviews it and submits it with its recommendation to the State Survey Agency (SA) and Accrediting Organization (AO), if applicable. Its seven parts cover the request type, the primary site, new extension sites, closures and address changes, conversions between primary and extension sites, existing extension sites and a legal contact.
The form's Paperwork Reduction Act notice shows OMB No. 0938-0273, expiring July 31, 2027. You can fill it out free in your browser on this page and download the result without an account.
A, for an initial request: Medicare, Medicaid or both, county, state, whether deemed status is sought and the accrediting organization. B, for a new extension site: the primary site's CMS Certification Number and the AO name, if deemed.
Legal and DBA names, street address, city, county, state, ZIP code and phone, services provided (physical therapy, speech pathology, occupational therapy or all), type of organization and type of control.
Full-time or part-time operation, with days and hours if part-time, and the number of physical therapists, speech pathologists and occupational therapists on staff and by arrangement.
The new site's legal and DBA names, address, phone, services provided and whether it will operate full-time or part-time, with its hours.
Part IV records an extension site closure with its date of termination, or an address change. Part V covers a primary location converting to an extension site and an extension site converting to the primary site.
Part VI lists up to four existing extension sites with their identification numbers. Part VII names the primary point of contact, followed by the authorized official's signature, title and date.
Complete Part I.A for an initial request, or select No for initial request and complete Part I.B for an existing OPT. The instructions say to answer all questions as of the current date of the request.
Complete Part II with names, address, services, type of organization, type of control, hours and qualified staff. The instructions say the county may be left blank if not known.
The instructions say to add the hours the professionals worked in the week ending before the week of filing, divide by the hours in the standard work week, and express the result in quarters (.00, .25, .50, .75).
List each new extension site in Part III, closures or address changes in Part IV and conversions in Part V. Part VI lists existing extension sites.
Part VII is required for all submissions, the instructions say. Enter the contact's name, title, email and phone, and the authorized official signs with title and date.
Include the form with the CMS-855 application to the MAC. The instructions say the SA or AO may also be copied on the request.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
With the CMS-855 application to the Medicare Administrative Contractor (MAC), which the instructions say submits it with its recommendation to the SA and AO, if applicable. For questions about where to submit documents, the form lists [email protected].
The instructions say an organization requesting multiple extension sites at the same time does not need a CMS-855 for every location: one CMS-855 and this form will suffice.
The form notes that if an organization sends an additional request within 90 days of a CMS-855 submitted to the MAC, processing delays could occur, because the MAC completes the first change before starting the second.
The instructions say to leave the CMS Certification Number blank on initial certifications and enter the six-digit provider number on recertifications. Extension identification numbers are left blank for new extension locations.
If an organization is uncertain how to complete some fields, the instructions say to contact the State Survey Agency (SA).
The form estimates an average of 15 minutes per response. Its notice gives OMB No. 0938-0273, while the page header prints OMB No. 0938-0065.
CMS-855A
1,236 fields, 72 pages
CMS-855B
960 fields, 54 pages
CMS-1561
14 fields, 2 pages
CMS-1539
51 fields, 2 pages
CMS-359
46 fields, 5 pages
The instructions name the requests the form covers and which parts each one uses. They also say Part VII is required for all submissions.
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It is the Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy (OPT) and/or Speech Pathology Services (OSP), for initial and extension site requests. The CMS page lists it as the Model Letter Requesting Identification of Extension Locations.
The instructions say to include it with the CMS-855 application submitted to the Medicare Administrative Contractor (MAC). The MAC then sends it with its recommendation to the SA and AO, if applicable.
No. The instructions say an organization requesting multiple extension sites at the same time can submit one CMS-855 with this form, listing each extension site in Part III.
The instructions say Part VII is required for all submissions. The other parts depend on the request: Part I.A and Part II for initial enrollment, Part I.B through Part III for a new extension site, and Parts IV or V for closures, address changes and conversions.
The instructions say to add the hours worked by the qualified professionals in the week ending before the week of filing, divide by the standard work week, and express the result as a quarter fraction. Only qualified physical therapists and speech pathologists are included.
The instructions say to contact your State Survey Agency (SA) if your organization is uncertain how to complete some fields. For questions about where to submit documents, the form lists [email protected].
