Submit your completed and signed original application with a check or money order payable to 'Commonwealth of Pennsylvania' to the following address: Pennsylvania Department of Health, Division of Home Health, 2525 N. 7th Street, Harrisburg, PA 17110. Ensure all sections of the form are filled out accurately, and all required documents are included. Retain a copy of your entire packet for your records. For any questions, contact the Division of Home Health. It is advised to track your submission to confirm its receipt and follow any further instructions provided by the Department of Health.

The application for the Pennsylvania Home Health Agency license does not specify any particular important dates for 2024 and 2025. However, ensure that you monitor the Department of Health's announcements or contact their office to stay updated on any potential changes in the process or deadlines.

The purpose of this form is to provide a standardized application for obtaining a Home Health Agency license in Pennsylvania. The application ensures that all necessary information is collected in a uniform manner, which facilitates a quick and accurate review process by the Department of Health. The form also clarifies the requirements and guidelines applicants must follow to ensure compliance with state regulations. By completing this form, applicants demonstrate their commitment to providing quality home health services in accordance with Pennsylvania's health regulations. The application includes various sections that collect critical information about the agency, such as identifying information, services offered, geographical service areas, and operational details. Additionally, applicants must submit supporting documentation, including a civil rights survey, health care provider details, and a payment agreement. Completing and submitting this form accurately and thoroughly is essential for obtaining the necessary licensure to operate a Home Health Agency in Pennsylvania. Failure to provide complete or accurate information could result in delays or denial of the license application, so it is crucial to follow all instructions carefully.

• 1. Name of Entity: The full legal name of the entity applying for the Home Health Agency license.
• 2. Doing Business As/Fictitious Name: Any other name under which the entity operates, if applicable.
• 3. Mailing Address: The mailing address of the entity, including street, city, state, and zip code.
• 4. Physical Site Address: The physical location of the entity's office, excluding PO Boxes, including street, city, state, and zip code.
• 5. County: The county where the physical site of the Home Health Agency is located.
• 6. Telephone: The primary contact phone number for the entity.
• 7. Fax: The fax number for the entity, if available.
• 8. Email Address: An active email address for contacting the entity.
• 9. Contact Person: The name of the individual responsible for correspondence related to the application.
• 10. Days and Hours of Operation: The hours during which the office is physically open for business, listed by day of the week.
• 11. Geographic Service Area by County: List of counties adjoining the agency's physical location where services will be provided.
• 12. Payment: A check or money order payable to 'Commonwealth of Pennsylvania' for the application fee.
• 13. Agreement: A statement of agreement to operate the Home Health Agency in accordance with state laws and regulations.
• 14. Affirmation: A signed affirmation that all information provided is true and correct to the best of the signer's knowledge.
• 15. Authorized Representative's Signature: The signature of the individual within the organization with the legal authority to execute the application.

If you fail to submit a complete application form, your application will be mailed back to you for corrections. Not addressing all required information and documents will lead to delays in the licensure process.

• Incomplete Information: Failure to provide all requested information may result in your application being rejected or delayed.
• Missing Supporting Documents: Not including required documentation can cause your application to be returned for revisions.
• Denied License: Providing inaccurate or incomplete information can result in the denial of your Home Health Agency license.
• Licensure Delays: Delays in the review process can occur if your application is not filled out accurately and thoroughly.
• Application Withdrawal: Failure to resubmit revisions within the given timeframe will result in your application being withdrawn from consideration.

• 1. License Application: New home health agencies applying for licensure in Pennsylvania.
• 2. License Renewal: Existing home health agencies renewing their licenses to continue operating.
• 3. Compliance: Organizations seeking to comply with Pennsylvania health regulations.
• 4. Authority to Operate: Healthcare providers requiring proper authority to operate legally.
• 5. Home Health Services: Businesses needing legal authorization to offer home health services.