Thank you for your interest in joining the network of Participating Providers with the Bureau of Family Health.

This page contains all the information you will need to apply for the Chronic Renal Disease Transportation PPA.

Note: The files listed below are in Adobe PDF format. You will need the free Adobe Acrobat Reader installed on your computer system in order to access, view and print the files. Click here for information on obtaining Adobe Acrobat Reader.
 
To enter into a PPA, you must (1) complete the agreement, several appendices and attachments, (2) sign the agreement and (3) return it to the Bureau. 
 
All necessary information and forms are available online.  All documents can be downloaded as either Adobe Acrobat or Microsoft Word files and printed.
 
Providers' Responsibilities 
 
Providers are responsible for submitting a COMPLETE and ACCURATE agreement.  Please comply with all the directions on the instructions page, including the submission of the mandatory appendices and attachments.   Incomplete or inaccurate PPAs cannot be processed.   

Providers who submit an incomplete PPA will receive a letter requesting the missing items required to complete processing.  If a provider does not respond timely to this request for additional information, the agreement will be rejected and returned. To reapply, the provider will need to start the process over and complete an entirely new PPA. 

PPA Process

Existing Provider:

If you have an existing PPA with the Bureau of Family Health with an upcoming expiration date, you should receive a letter approximately three months prior to that date notifying you that your PPA is about to expire.  To obtain a new PPA, please follow the steps listed below.  Once the PPA forms are submitted correctly, you will receive a new PPA number and new effective and termination dates.  If you have any questions about the process please call 717-772-2762.  The Bureau will only process invoices with dates of service that fall within the effective and termination dates of a fully executed agreement.

New Provider:

To obtain a new PPA, please follow the steps listed below.  Once the PPA forms are submitted correctly, you will receive a PPA number and the effective and termination dates for the PPA.  If you have any questions about the process please call 717-772-2762.  The Bureau will only process invoices with dates of service that fall within the effective and termination dates of a fully executed agreement.

Step 1: Print each of these documents  

Signature Page, Appendices and Attachments [PDF]  

Form W-9 [PDF]  

Instructions [word]  

Contact Information [word]  

Step 2:  Complete PPA signature page and gather all required documentation (Signature page, Appendix A, Appendix B, Appendix C, contact information and W-9 Form). Type or print all information so that it is legible.  If you choose to complete the information by hand, you must use a non-erasable, blue or black point pen.  Do not use pencil. Do not fold the PPA package - especially the signature page.  

Step 3:  Attach all required supporting documentation.  Check the Provider Checklist to ensure that all required items are submitted with your agreement.  

Step 4:  Keep a copy of your completed PPA package for your records.

Step 5:  Send entire agreement via overnight mail (Signature page, Appendix A, Appendix B, Appendix C, contact information and W-9 Form) to:

ATTN:  Chronic Renal Disease Program
Pennsylvania Department of Health
Division of Child and Adult Health Services
625 Forster St.
7th Floor East Health & Welfare Building
Harrisburg, PA  17120-0701