- Form #
- CMS 1856
- Form Title
- Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
- Revision Date
- 12/11/2006
- O.M.B. #
- 0938-0065
- O.M.B. Expiration Date
- 08/31/2014
- CMS Manual
- N/A
- Special Instructions
- N/A
