Speech language pathologist

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Home ► Speech language pathologist

Last Modified: 4/17/2025 Location: FL, PR, USVI Business: Part A, Part B

Speech language pathologist

Qualification requirements

A qualified speech-language pathologist is an individual who has a master's or doctoral degree in speech-language pathology, and who meets either of the following requirements:

1. Is licensed as a speech-language pathologist by the state in which the individual furnishes such services; or

2. In the case of an individual who furnishes services in a state which does not license speech-language pathologists:

a. Has successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating supervised clinical experience)

b. Performed not less than 9 months of supervised full-time speech-language pathology services after obtaining a master's or doctoral degree in speech-language pathology or a related field; and

c. Successfully completed a national examination in speech-language pathology approved by the Secretary

• Provide services as a speech language pathologist in one of the following types of practices:

• Solo practice

• Partnership

• Group practice

• An employee of a solo practice, partnership, or group practice

Documentation requirements and recommendations

• Completed CMS-855I form external pdf file

Note: To expedite the processing of your provider enrollment application, you may use the internet-based PECOS external link

, which will automatically select the appropriate form and allow you to complete the application process online.

• Signed and dated certification statement -- all signatures must be original and signed in ink (blue ink preferred). Stamped, faxed, or copied signatures will not be accepted.

Note: If you submitted your application through internet-based PECOS, you may sign the application electronically or you must submit your paper certification statement within 15 days of your electronic submission.

• Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) external pdf file

and associated documentation (e.g., copy of a voided check or a bank letter). Please click here for more information.

Note: If a provider or supplier already receives payments electronically and is not making a change to his or her banking information, the CMS-588 is not required. In addition, physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588.

• Include copies of the following supporting documents:

Note: A provider or supplier located in Puerto Rico or U.S. Virgin Islands must include a copy of his or her Letter of Good Standing. The letters for Puerto Rico providers or suppliers will be considered valid if it was issued within 12 months of First Coast’s receipt of the enrollment application. The letters for U.S. Virgin Islands providers or suppliers will be considered valid if it was issued within six months of First Coast’s receipt of the enrollment application.

• Certificate of completion, transcript, or diploma from accredited educational program(s) required for certification or licensure (please refer to Qualification requirements section at the top of the page).

Additional documentation requirements (when applicable)

Medicare may require additional documentation, when applicable, to validate key information contained within the enrollment application (e.g., name change, tax identification number, proof of citizenship) or to address specific issues that could adversely affect a practitioner’s potential eligibility for enrollment (e.g., adverse legal actions, financial relationships).

• NPI verification from National Plan and Provider Enumeration System (NPPES) -- only durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers are required to submit this type of documentation

• Written confirmation from the IRS verifying provider’s TIN is associated with the provider’s legal business name (e.g., IRS CP 575)

• Final adverse action documentation: Please include copies of legal documents associated with any final adverse action(s) taken against the provider as well as copies of any legal documents showing its resolution (e.g., notifications, reinstatement letters)

Note: Documents containing a summary of the adverse actions taken or their resolution will not be accepted

• Completed Medicare Participating Physician or Supplier Agreement (CMS-460) external pdf file

• Statement in writing from the practitioner’s bank (or other financial institution) -- if Medicare payments will be sent to a practitioner’s bank with which he or she has a lending relationship (i.e., any type of loan), then the practitioner must provide a statement in writing from the bank -- which must be specified in the loan agreement -- that the lender has agreed to waive its right of offset for Medicare receivables

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