Rural Health Clinic Application

​​​Federal Medicare Regulations

Application Materials

• Submit one copy of the CMS Form 29 to the Division of Home Health
• Submit one copy of the CMS Form 690 to the Division of Home Health.
• Submit one copy of the CMS Form 1561a to the Division of Home Health.
• Submit the CMS Form 855A - Enrollment Application to your Fiscal Intermediary.
• Submit the Federal Civil Rights Information for Medicare Applicants.

After review and acceptance of the application materials and notification from CMS of the approval of the CMS-855A, the department will conduct a survey before recommending the agency for Medicare certification.

Email completed forms to: ra-dhhmedicarechnges@pa.gov

Questions?
Email ra-dhhmedicarechnges@pa.gov

CMS Approved Accreditation Organizations

• The Compliance Team (TCT)
  
• American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
• The Joint Commission

• Rural health clinic regulations
  
• Initial Medicare Certification Surveys