Federal Medicare Regulations
Application Materials
- Submit one copy of the CMS Form 1856 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. 7th Street
Harrisburg, PA 17110
Questions?
Email ra-dhhomehealth@pa.gov