Completing and Submitting the PPA

Thank you for your interest in joining the network of Participating Providers with the Refugee Health Program.
 
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 Refugee Health Program Administrator at:

ATTN:  Refugee Health Program Administrator
Pennsylvania Department of Health
Office of Health Equity
625 Forster Street
Room 628 Health & Welfare Building
Harrisburg, PA   17120-0701

All necessary information and forms are available online.  All documents can be downloaded as either Adobe Acrobat files and printed.   
 
For questions, please visit the
FAQs section or Contact Us
    
 
Overview for Completing and Submitting the PPA
 
         Step 1:  Download and print all required forms.
         Step 2:  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.
         Step 3:  Attach all required supporting documentation.
         Step 4:  Keep a copy of your completed PPA package for your records.
         Step 5:  Send the completed PPA package with original signatures and all 
                     required documentation to the address indicated. Do not fold the
                     PPA package - especially the signature page. 
  

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
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. 

Step 1:
Print each of these documents

Refugee Health Cover Letter [PDF]
PPA and Related Documents [PDF]
Form W-9 [PDF]
Instructions [PDF]

Step 2:
  Complete PPA signature page and gather all required documentation (Signature page, Appendix A, Appendix B, Appendix C, Appendix D, Appendix E, Appendix F, Appendix G, and Appendix H, contact information and W-9 Form).  Do not fold the PPA package - especially the signature page.

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

Step 4:
  Send entire agreement via overnight mail (Signature page, Appendix A, Appendix B, Appendix C, Appendix D, Appendix E, Appendix F, Appendix G, Appendix H, contact information and W-9 Form) to:

ATTN:  Refugee Health Program Administrator
Pennsylvania Department of Health
Office of Health Equity
625 Forster Street
Room 628 Health & Welfare Building
Harrisburg, PA   17120-0701