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Skip Navigation LinksPennsylvania Department of Health > Healthcare Facilities > Consumers > Health Facilities > Home Health Services and Hospices > Hospice Licensure

​Hospice Agency State Licensure and/or Federal Medicare Certification

 

Hospice Agency Application Materials:

Initial Hospice Application

If your application is in accordance with Pa. 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.


Hospice Agency Application for Federal Medicare Certification:

NOTE: State licensure as a Hospice Agency is a requirement for Federal certification.

Please submit one copy of the ​CMS Form 417 to the Division of Home Health.

Please submit one copy of the CMS Form 690 to the Division of Home Health.

​Please submit one copy of the CMS Form 1561 to the Division of Home Health.

Please submit the CMS Form 855A - Enrollment Application to your Fiscal Intermediary - see Helpful Links on the right.

Please submit the Federal Civil Rights Information for Medicare Applicants by clicking here.

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.

 

All forms and regulations are accessible by using Adobe Reader software.   Click here to download it.