Providers of Outpatient Physical Therapy and/ or Outpatient Speech Pathology Services Certification Program
(Note: Items below that are underlined and in italics are links to additional information)
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: http://www.in.gov/pla/
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:
Therapist in Private Practice or Group Practice
Other Certification Programs
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 State Department of Health (ISDH). Please go to the Indiana Medicaid Provider website for additional forms that must be completed to enroll as a provider: http://provider.indianamedicaid.com/.
Contact the Program
Indiana State Department of Health
Division of Acute Care
2 North Meridian Street, 4A
Indianapolis, IN 46204
(317) 233-7474 (Acute Care Receptionist)
(317) 233-1325 (ISDH Main Switchboard)
(317) 233-7472 [Administrative Assistant]
Applying for Initial Certification
Select a topic below for instructions on how to submit an application for Certification as an Outpatient Physical Therapy and /or Outpatient Speech Pathology Services Provider.
Program Information and Policies
Select a topic below.
Medicare Resources from the Medicare Learning Network (MLN)
Select a topic below.
Select a topic below for instructions on what forms to use for changes.
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
Select a topic below for instructions on how to submit the change to ISDH. Please notify ISDH of changes as they occur.
Adding an Extension site
Report a Complaint or Incident to the ISDH
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 State Department of Health of a reportable incident pursuant to the ISDH 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.