Outpatient Physical Therapy/Speech-Language Pathology Providers
Change of Ownership 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 report a Change of Ownership, you must complete the required application packet. Refer to 42 CFR Part 485, Subpart H for the Conditions Of Participation For Outpatient Physical Therapy and Speech-Language Pathology Services.

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. 

Please refer to the following links to get started:

• Pro​​vider Instructions (PDF)
• Provider Checklist ​
  

Application Packet Forms

• HS 200 – Licensure and Certification Application (PDF, 1.5MB)
  
• HS 215A – Applicant Individual Information (PDF)
• HS 309 – Administrative Organization (PDF)
• STD 850 – Fire Safety Inspection Request (PDF)
  
• HS 328 – Notice – Effective Date of Provider Agreement (PDF)
• CMS 1561 – Health Insurance Benefits Agreement (PDF)
• CMS 1856 – Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services (PDF)
• CMS 855A - Medicare General Enrollment Health Care Provider/ Supplier Application​​​ (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