PA DPW Provider Enrollment Base Application 2011 free printable template

INSTRUCTIONS FOR COMPLETION OF PENNSYLVANIA Promise TM PROVIDER ENROLLMENT BASE APPLICATION Applications must be typed or completed in black ink, or they will not be accepted. Applications will be

How to fill out filler promise provider enrollment

How to fill out PA DPW Provider Enrollment Base Application

1. Obtain the PA DPW Provider Enrollment Base Application form from the official website or local DPW office.
2. Fill out the general information section, including your name, address, and contact details.
3. Provide details about your practice, including type of services offered and location.
4. Include your tax identification number (TIN) and relevant licensing information.
5. Complete the security and background checks section as required.
6. Attach any necessary supporting documents, such as proof of insurance and professional licenses.
7. Review your application for accuracy and completeness.
8. Submit the completed application to the appropriate DPW office for processing.

Who needs PA DPW Provider Enrollment Base Application?

1. Healthcare providers who wish to participate in Pennsylvania's Medical Assistance program.
2. Individuals or organizations providing services covered under the Pennsylvania Department of Public Welfare.
3. New providers seeking enrollment to offer Medicaid services to eligible clients.

People Also Ask about

What is Pennsylvania Enrollment Services?

PA Enrollment Services is here to help you choose the best health plans and doctors for you and your family.

What is the phone number for PA Enrollment Services?

If you still want help, you can call our PA Enrollment Services at 1-800-440-3989 (TTY 1-800-618-4225).

What is the income limit for medical assistance in PA 2023?

The 2023 maximum is $148,620, and the 2023 minimum is $29,724.

What is pa provider eligibility program?

This program provides services to eligible persons with physical disabilities in order to prevent institutionalization and allows them to remain as independent as possible. Eligibility: Recipients must be between the ages 18–59, physically disabled, mentally alert, and eligible for nursing facility services.

What is Pennsylvania Enrollment services?

PA Enrollment Services is here to help you choose the best health plans and doctors for you and your family.

What is a PA PROMISe ID?

Q: WHAT IS THE PROMISe ID? A: The PROMISe, or Provider Reimbursement and Operations Management Information System, ID is an identification number issued by the Pennsylvania Department of Human Services (Department or DHS).

What is the monthly income limit for medical assistance in PA?

If a non-married person applying for benefits has more than $2,742 of gross monthly income, then the resource limit for countable (non-exempt) resources is $2,400. If the applicant has gross income which is $2,742 or less, then the person's resource limit is $8,000.

Is Pennsylvania access card Medicaid?

ACCESS CARD INFORMATION: ➢ Enclosed is your PA ACCESS Card, a permanent, yellow plastic card issued to each individual who is eligible for Medicaid.

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What is PA DPW Provider Enrollment Base Application?

The PA DPW Provider Enrollment Base Application is a form used by healthcare providers in Pennsylvania to enroll in the Department of Public Welfare (DPW) program, which allows them to receive reimbursement for services provided to Medicaid recipients.

Who is required to file PA DPW Provider Enrollment Base Application?

Healthcare providers who wish to provide services to Medicaid recipients and receive payment from Pennsylvania's Department of Public Welfare are required to file the PA DPW Provider Enrollment Base Application.

How to fill out PA DPW Provider Enrollment Base Application?

To fill out the PA DPW Provider Enrollment Base Application, applicants should provide accurate information regarding their business entity, including tax identification numbers, service specialties, and any relevant licensing information, and follow the instructions provided with the application form.

What is the purpose of PA DPW Provider Enrollment Base Application?

The purpose of the PA DPW Provider Enrollment Base Application is to ensure that healthcare providers meet the necessary qualifications and standards to provide services to Pennsylvania Medicaid recipients and receive appropriate reimbursement for those services.

What information must be reported on PA DPW Provider Enrollment Base Application?

The application must report information such as provider type, business address, tax identification numbers, Medicaid numbers, professional credentials, and details about the services offered.