Outpatient Physical Therapy/Speech-Language Pathology Providers
Change of Certification Application Packet

A rehabilitation clinic may be certified as an Outpatient Physical Therapy and Speech-Language Pathology (OPT/SP) provider in California. An OPT/SP is a rehabilitation agency that provides an integrated interdisciplinary rehabilitation program designed to upgrade the physical functioning of handicapped disabled individuals by bringing specialized rehabilitation staff together to perform as a team and provides at least physical therapy or speech-language pathology services, pursuant to Title 42 Code of Federal Regulations (CFR) section 485.703.  ​

To apply for [Medi-Cal and/or Medicare] certification to a health facility, you must complete the required application packet.

How to Apply

An applicant must submit a completed application packet to the Centralized Applications Branch (CAB). The provider instructions are a resource to guide you through the process. The provider checklist identifies the required forms and supporting documents needed to apply for licensing. The Sample Application Packet is a visual aid that displays a sample of the completed forms contained in the application packet.

Please refer to the following links to get started:

• Provider Instructions​​
  
• Provider Checklist​
  

Application Packet Forms

• HS 200 – Licensure and Certification Application (PDF, 1.5MB)
  
• DHCS 1051 - Civil Rights Compliance Review (PDF)
  
• DHCS 9098 – Medi-Cal Provider Agreement​ (PDF)
  
• HS 328​ - Notice - Effective Date of Provider Agreement ​(PDF)
• ​​​CMS 29​ - Request to Establish Eligibility​ (PDF) 
  
• CMS 855B​ - Medicare Enrollment Application (Institutional Providers) (PDF)
  
• CMS 1561​ - Health Insurance Benefit Agreement (PDF)
  
• CMS 3427​ - ESRD Application Notification ad Survey Report​ (PDF)​
• HHS 690 – Assurance of Compliance (PDF)

Where to Submit Applications

Submit completed application packets to the CAB at the address listed below. Do not send any completed application packets, forms, or supporting documents to the local CDPH, District Office.

          California Department of Public Health
          Licensing and Certification Program
          Centralized Applications Branch
          P.O. Box 997377, MS 3207
          Sacramento, CA 95899-7377​