State Licensure and/or Federal Medicare Certification

A home health care agency is defined by the Pennsylvania Department of Health as "... an organization staffed and equipped to provide skilled nursing care and at least one other therapeutic service - home health aides, physical therapy, speech therapy, occupational therapy, or medical social services - to persons on a part-time basis or intermittent basis in their place of residence (PA Code 28 §601.6)."

If the above definition is met, complete the following document to apply for state licensure.

Home Health Agency Application Materials

ALL applications MUST BE MAILED to the address listed below.

• Initial Home Health Application
  

If your application is in accordance with Pennsylvania home health agency rules and regulations, the division will issue you a license.  Please keep in mind the length of time for the licensure process depends upon the accuracy of information provided.

Home Health Agency Application for Federal Medicare Certification

NOTE: State licensure as a home health agency is a requirement for federal certification.

• Submit one copy of the CMS Form 1572(a) 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 1561 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.

Mail completed forms to:
Please note change of address
Pennsylvania Department of Health
Division of Home Health
2525 N. 7^th Street
Harrisburg, PA 17110

Questions?
Email ra-dhhomehealth@pa.gov

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