Providers of Outpatient Physical Therapy and/ or Outpatient Speech Pathology Services Certification Program

Welcome to the Providers of Outpatient Physical Therapy and /or Outpatient Speech Pathology Services Certification Program Homepage. The types of therapy services provided under this program include Outpatient Physical Therapy, Outpatient Speech Pathology Services, and Outpatient Occupational Therapy (only in combination with Physical Therapy and/or Speech Pathology Services).

In the State of Indiana, providers of Outpatient Physical Therapy and /or Outpatient Speech Pathology Services are not licensed. However, individuals performing therapy (Physical Therapist, Speech Pathologist, Occupational Therapist, etc) are licensed or certified as appropriate for the types of services they provide. Please see the Indiana Professional Licensing Agency (IPLA) for further information.

To be reimbursed by Medicare in the State of Indiana for Outpatient Therapy Services you must be a Therapist in Private practice or Group Practice certified for Medicare, certified as a Provider of Outpatient Physical Therapy and /or Outpatient Speech Pathology Services, or be certified in one of the Other Certification Programs and follow Medicare requirements for that provider type.

To be reimbursed by Medicaid you must either be certified as a provider or supplier for Medicare as listed above or apply for Medicaid only using the same forms.  The only form you would not complete is the 855 application and you would send documents to the Indiana Department of Health (IDOH).  Please go to the Indiana Medicaid Provider website for additional forms that must be completed to enroll as a provide.

Report a Complaint or Incident to the IDOH

Report a complaint regarding a health care facility
Individuals can call or email to make complaints about care provided at any licensed or certified Indiana health care providers or suppliers.

Report an incident regarding a health care facility
The Incident Report Form is for health care facilities to notify the Indiana Department of Health of a reportable incident pursuant to the IDOH Reportable Unusual Occurrence Policy.  The Incident Report Form is also for health care facility staff (nursing homes, intermediate care facilities, and hospice agencies) to report a reasonable suspicion of a crime against a resident pursuant to Federal regulations.  This form is not to be used to file a complaint.

Applying for Initial Certification

Initial Certification

Forms

Summary of when to use what forms

• Form CMS-1856 (Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services)
• Form CMS-381 (Model Letter Requesting Identification of Extension Units)
• Form 55642 (Extension Site Questionnaire)
• Form CMS-1561 (Health Insurance Benefits Agreement)
• Evidence of successful electronic submission of the Form HHS 690 civil rights attestation and check list. Please complete all required Office of Civil Rights procedures for providers as listed on their website: http://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/index.html

Contact the Program