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Requirements for Provider Type 17 -Therapist - pa physical therapy license

Requirements for Provider Type 17 -Therapist-pa physical therapy license

Requirements for Provider Type 17 - Therapist
Specialty Code
Please choose from the following for the specialty and code:
? 170 - Physical Therapist
? 171 - Occupational Therapist
? 173 - Speech/Hearing Therapist
? 174 - Art Therapist
? 175 - Music Therapist
? 558 - Behavior Specialist for Children with Autism
Provider Eligibility Program (PEPs)
? Consolidated Waiver
? Adult Autism Waiver
? Community Living Waiver
? Fee-For-Service
? Independence Waiver
? OBRA Waiver
? ODP Base Program
? Person/Family Directed Support Waiver
Required Documents for Provider Type 17:
The following documents and supporting information are required by the Bureau of Fee-For-Service Programs to enroll as a
provider: (please ensure all documents are legible)
? Completed application for the enrollment of an Individual Practitioner--application must include:
o Signed Provider Agreement with original signature of enrolling Provider; and
o Completed Ownership or Control Interest Disclosure form
? If the Provider is not a citizen of the United States, please submit a copy of the Permanent Resident Card or Form I-797
showing authorization to work in the United States
? Copy of Applicable License **
o If applying for PT 17/170 Physical Therapist, submit physical therapy license
o If applying for PT 17/171 Occupational Therapist, submit occupational therapist license
o If applying for PT 17/173 Speech/Hearing Therapist, submit Speech Pathologist or
Audiologist license
o If applying for PT17/174 Art Therapist, submit clinical social worker, marriage and family therapist, professional
counselor or related license**
? Proof of home state Medicaid participation (out of state providers)
? Letter of certification for Nurse Family Partnership providers
? for additional information or requirements.
? For specialty 174, Art Therapist, submit proof of certification from the Art Therapy Credentials Board (ATCB)
? For specialty 175 Music Therapy, submit proof of board certification as a music therapist
Office of Developmental Program Providers:
? If applying to be an Art or Music Therapist in the following provider eligibility waiver programs: Consolidated Waiver,
Community Living Waiver, ODP Base Program or the Person/Family Support Waiver, licensure is not required. However,
providers should visit myodp.org for more information on becoming a provider for the Office of Developmental
? For specialty 173, Speech/Hearing Therapist, submit a copy of SPeCTRUM training certificate if applying to be an Adult
Autism Waiver provider.
Therapists are encouraged to apply electronically via the Electronic Provider Portal, available at
https://provider.enrollment.dpw.state.pa.us/ . If unable to enroll electronically, please send the paper application and all
required documents to:
DHS Provider Enrollment
PO Box 8045
Harrisburg, PA 17105-8045
Fax: (717) 265-8284
E-mail: RA-ProvApp@pa.gov

How to become a physical therapist in Pennsylvania? All applicants must be at least 20 years of age or more. Graduate from a Pennsylvania physical therapy assistant training program approved by the CAPTE of the APTA. Have a passing score on the NPTAE.