Certification

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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.

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

CMS Approved Accreditation Organizations

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

Content Editor ‭[2]‬

Rural Health Clinic Application

​​​Federal Medicare Regulations

Application Materials

CMS Approved Accreditation Organizations

Content Editor ‭[1]‬

Federal Medicare Regulations