Please type all responses in the application materials ...

1 Please type all responses in the application materials . Handwritten submissions will not be accepted. Hand delivery of the application is not accepted. Applications must be mailed in. Dear Applicant: The following series of documents contain the application materials for a Home Care Agency/Home Care Registry. Please note that all questions must be answered, and all requested supporting documentation must be provided. Please label all the exhibits. If you fail to submit all of the requested information, the application materials will be mailed back to you. If you submit a complete application , to include all the required supporting documentation, an email will be sent to the contact email listed on the application .

2 Do not include information not specifically requested. If your application is in accordance with Pennsylvania Home Care Agency rules and regulations, the Division of Home Health will issue you a license. Please keep in mind the length of time for the licensure process depends upon the accuracy of information provided. If it is determined that corrections need made to the information you submitted, an email will be sent to the email address you provide in the application materials . You will be given 30 days from the date of the email to resubmit revisions to your policies. Failure to resubmit in a timely fashion will result in your application being withdrawn from consideration.

3 Sincerely, Division of Home Health Initial Home Care Agency/Registry application Revised August 30, 2021 Page | 1 Initial Home Care Agency/Registry application Revised August 30, 2021 Page | 2 Initial Home Care Agency/Registry Licensure application Checklist This checklist must be included/submitted with the initial application . The purpose of this checklist is to ensure that you complete and submit ALL required documents. Your signature on the application is an acknowledgement that you have reviewed the regulations and requirements listed below, for obtaining a home care license. Checklist: Read the Chapter 51 regulations for health care facilities, found at the following link: Read the Chapter 611 regulations for home care agencies/registries at the link below, and print a copy to keep at your agency: Read the Health Care Facilities Act, found at the following link.

4 Completed/Signed the Identifying Information of Home Care Agency/Registry A check/money order, made payable to Commonwealth of PA for $ Completed/Signed Password Agreement form (only one person can be listed as the contact person) Completed Civil Rights Survey A copy of your agency s non-discrimination policy Completed Home Care Agency/Registry Licensure Survey A copy of direct owner criminal background check dated within a year prior to application submission and based on residency --- refer to regulations. A copy of direct owner child line clearances (if applicable) Exhibit L, as described in #12 of the form , to include the Consumer Notice of Direct Care Worker Status form (an example of the Consumer Notice of Direct Care Worker status form is included in this initial application ) Required policies included (Be sure to label the exhibits accordingly).

5 Completed Information Requested of Healthcare Providers Applying for a License to Operate a Healthcare Facility form 10 questions physically answered. All parts of each questions must be answered. Extra pages may be attached if more space is needed. Copy of direct owner s resume and/or administrator s resume (if the administrator is not the direct owner) Copy of Department of State business registration confirmation and fictitious name registration (screen shots will not be accepted). Copy of Proof of EIN (SS4 approval form ) Initial Home Care Agency/Registry application Revised August 30, 2021 Page | 3 Review your entire application . Remove information that is not specifically requested in the application materials .

6 Before submitting a completed application , be sure to make a complete copy for your safe keeping. (The Division will not provide you with a copy of your application after your facility has been licensed). Initial Home Care Agency/Registry application Revised August 30, 2021 Page | 4 Identifying Information for Home Care Agency/Registry License Please check the one that applies: Home Care Agency Home Care Registry Home Care Agency & Home Care Registry Name of Entity: Doing Business As/Fictitious Name: Mailing Address: Street City State Zip Code Physical Site Address: (No PO Boxes) Street City Zip Code County: Telephone: Fax: Email Address (must be an active email address): Contact Person: Days and Hours of Operation: Physically present in office Monday Tuesday Wednesday Thursday Friday Saturday Sunday NOTE.

7 An on-site inspection by surveyors will occur during the business hours submitted. List of Geographic Service Area by County: Must be adjoining counties from physical location of agency Please indicate if the agency will have 24-hour on-call system. Initial Home Care Agency/Registry application Revised August 30, 2021 Page | 5 Payment A Check or Money Order Payable to Commonwealth of Pennsylvania for the amount of the fee must accompany this application . Currency is not acceptable. The regular fee per license is $100. Mail the completed and signed original application with a check or money order to: Pennsylvania Department of Health Division of Home Health 555 Walnut Street, 7th Floor Harrisburg, PA 17101 IMPORTANT: Please retain a copy of your entire packet for your records.

8 Agreement application is made to operate a Home Care Agency/Home Care Registry in accordance with Chapter 8 of the Health Care Facility Act (35 et. seq.). application includes Initial application form with payment, Civil Rights Survey, Information requested of Health Care Providers applying for a license, and Initial Home Care Agency / Registry Licensure Survey. I agree that all of the identifying information on this form and information furnished on the aforementioned attached documents and all other materials submitted are complete and true. I understand that incomplete or inaccurate information IS REASON FOR DENYING THE ISSUANCE OF A LICENSE. I further agree to conduct said facility in accordance with the laws of the Commonwealth of Pennsylvania and with the rules and regulations of the Department of Health.

9 Affirmation The undersigned hereby affirms that the foregoing information is true and correct to the best of said persons knowledge, information and belief; said affirmation being made subject to the penalties prescribed by 18 Pa. 4904 (unsworn falsifications to authorities). Authorized Representative s Signature* Date Print Name of Authorized Representative Date *Authorized Representative the individual within the Applicant organization with the legal authority togive assurances, make commitments, enter into contracts, and execute documents on behalf of theApplicant, including this application . The signature of the Authorized Representative certifies thatcommitments made on this application will be honored and ensures that the Applicant agrees to conformto applicable law and Home Care Agency/Registry application Revised August 30, 2021 Page | 6 Provider/License Number: Initial Applicants: This section is for Dept.

10 Use Only Password Agreement I, (Name) hereby certify that effective (date became administrator), I am the Administrator/Director/Chief Executive Officer for (Facility Name) and that I am responsible for submitting a Plan of Correction in response to deficiencies cited by the Pennsylvania Department of Health on CMS form 2567. acknowledge receipt of the facility identification number and my individualpassword (which will be provided after receipt of this agreement) from thePennsylvania Department of agree to main the confidentiality of both the facility identification number and recognize and acknowledge that the use of my password to electronically submit aPlan of Correction, in response to deficiencies cited on the CMS form 2567,identifies me as the signer of the Plan of further recognize and acknowledge that the use of my password, in conjunctionwith the submission of a Plan of Correction, authorizes the PennsylvaniaDepartment of Health to conclusively accept that electronic Plan of Correction asmy authorized have had the opportunity to review this Agreement and hereby agree to the above statements.