​The purpose of this AFL is to clarify AFL 10-14, which served as a reminder of the CMS annual reporting requirement of extension locations. The clarifying content in this AFL has been underlined. The remaining content remains unchanged from AFL 10-14.

Pursuant to CMS Provider Certification Manual, Pub. 100-07 State Operations, Chapter 2, Section 2300 (Transmittal 16, dated January 10, 2006), all OPT/SPs are required to annually provide notification of Extension Locations, using Form CMS-381, to the California Department of Public Health (CDPH).

Each OPT/SP provider that provides services from extension locations is to indicate, in the appropriate spaces, the name, address and the provider number of the primary site, as well as the name(s) and address(es) of extension location(s) and, under Part B, the specific services (OPT1, OSP2, OOT3) each extension location provides.

Providers are required to return completed CMS-381 forms (attached) to their local district office within 40 days of the date of the Department’s letter. Previously AFL 10-14 required the CMS-381 form to be received within 30 days; an additional 10 days has been added to allow for mail delivery. Should the CMS-381 form(s) not be completed and returned by the provider to the district office, the OPT/SP provider may be notified that the lack of response "may result in denial of Medicare participation."

CDPH will update the CMS ASPEN/ACO database within 60 days of receipt of any completed CMS-381 Form.

Questions regarding the information provided in this AFL should be directed as follows:

Providers located in the Northern California region, contact Maelin Perez, OTR/L, Occupational Therapy Consultant, at (916) 552-8644.

Providers located in the Southern California region, contact Marialice Hawkins, OTR/L Occupational Therapy Consultant, at (323) 869-8504 or (323) 869-8500.

Sincerely,

Original Signed by Pamela Dickfoss

Pamela Dickfoss
Acting Deputy Director 

Attachment:

CMS 381 - Model Letter Requesting Identification of Extension Locations