State Licensure and/or Federal Medicare Certification

Hospice Agency Application Materials

ALL applications MUST BE MAILED to the address listed below.

• Initial Hospice Application
  

If your application is in accordance with Pennsylvania state licensure 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.

This step is for Inpatient Hospice Units:

Architectural construction plans for your proposed facility must be submitted to the Division of Safety Inspection for review and approval.

Mr. Charles Schlegel, Director
Division of Safety Inspection
2525 North 7^th Street, Suite 210
Harrisburg, PA 17110
Phone: 717-787-1911 or visit the building safety page.

Hospice Agency Application for Federal Medicare Certification

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

• Submit one copy of the CMS Form 417 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

DHS - Child Abuse Clearance Form

PA State Police - Criminal Background Checks

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