PA PROMISe Provider Enrollment Facility/Agency Application 2018-2026 free printable template

INSTRUCTIONS FOR COMPLETION OF PENNSYLVANIA Promise PROVIDER ENROLLMENT FACILITY/AGENCY APPLICATION Table of Contents Instructions Facility/Agency Application Provider Agreement Provider Disclosure

How to fill out PA PROMISe Provider Enrollment FacilityAgency Application

How to fill out PA PROMISe Provider Enrollment Facility/Agency Application

1. Obtain the PA PROMISe Provider Enrollment Facility/Agency Application form from the official Pennsylvania Department of Human Services website.
2. Read the instructions thoroughly to understand the requirements and necessary documentation.
3. Fill out the application form with accurate and up-to-date information about your facility/agency.
4. Provide documentation such as proof of licensure, tax identification number, and any other required credentials.
5. Review the completed application for any errors or omissions.
6. Sign and date the application where indicated.
7. Submit the application via the specified method (online, email, or mail), along with any supporting documents.

Who needs PA PROMISe Provider Enrollment Facility/Agency Application?

1. Any healthcare facility or agency seeking to provide services and receive reimbursement from Medicaid in Pennsylvania needs to complete the PA PROMISe Provider Enrollment Facility/Agency Application.

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Definition: Proposal form is the most important and basic document required for life insurance contract between the insured and insurance company. It includes the insured's fundamental information like address, age, name, education, occupation etc. It also includes the person's medical history.

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Form 1095-A, Health Insurance Marketplace Statement. The Health Insurance Marketplace (Marketplace) sends this form to individuals who enrolled in coverage there, with information about the coverage, who was covered, and when.

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IRS Form 1095-A It is a federal tax document that serves as proof of coverage for individuals to claim the premium tax credit. If you bought your health plan through Covered California, you should receive a 1095-A form from Covered California, whether or not you received state or federal premium assistance.

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What is PA PROMISe Provider Enrollment Facility/Agency Application?

The PA PROMISe Provider Enrollment Facility/Agency Application is a form used in Pennsylvania for facilities and agencies to enroll as providers in the Medical Assistance program, allowing them to offer services and receive reimbursements.

Who is required to file PA PROMISe Provider Enrollment Facility/Agency Application?

Any healthcare facility or agency wishing to provide services to Medical Assistance beneficiaries in Pennsylvania must file the PA PROMISe Provider Enrollment Facility/Agency Application.

How to fill out PA PROMISe Provider Enrollment Facility/Agency Application?

To fill out the PA PROMISe Provider Enrollment Facility/Agency Application, complete all required sections accurately, provide supporting documentation as needed, and submit the application through the designated submission channels.

What is the purpose of PA PROMISe Provider Enrollment Facility/Agency Application?

The purpose of the PA PROMISe Provider Enrollment Facility/Agency Application is to establish and verify the qualifications of facilities and agencies to ensure they meet state and federal standards for providing medical services.

What information must be reported on PA PROMISe Provider Enrollment Facility/Agency Application?

The application requires reporting information such as facility name, address, type of services provided, ownership structure, and credentials of the staff, along with any required licenses or certifications.