Participating Provider Agreement Form 815

Step one. Central Vendor Management Unit (CVMU): If you are already registered with CVMU, you do not need to register, please move on to Step 2. If you are not registered, register as a non-supplier provider and fill out the W-9 form at the bottom of the registration form before clicking on SUBMIT. An agreement through participating providers (PARTI) is a legal and binding agreement that is used by the Family Health Office to pay for health services on the basis of a pricing plan. By signing an AA, the provider undertakes to provide services in accordance with the PPP. Benefits are reimbursed on the basis of a conditional royalty plan that delineates the authorized procedure and the maximum fee allowed. To be reinstated for the services provided, the provider must have an up-to-date AAE and the patient must be registered with the Office at the time of the services. All service providers wishing to do business with the Commonwealth must be registered with the Central Vendor Management Unit (CVMU) and the Department of State (DOS). If you are not yet registered, you must do so before you can reach an agreement with the Bureau. Step two. Department of State (DOS): Make sure that the name of the organization of the entity with which you registered under DOS corresponds to the registration to the CVMU. If your entity name has changed, this information must be updated with DOS before it can proceed to Step 3. Step three.

Once you have registered on CVMU and DOS, please choose from the list below the type of provider that most accurately describes the services you have offered. Chronic Kidney Disease – Medical Services – Chronic Kidney Disease – Transportation For any questions, call 717-772-2762.

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