PHA Contact Form
Use this form to submit questions, issues or needs to the Pennsylvania Homecare Association. Our representatives will respond timely to all submissions!
Date Question/Form Submitted
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Provider Contact Name
*
First Name
Last Name
Provider/Agency Name
*
Is Agency an active Pennsylvania Homecare Association Member?
*
Please Select
Yes
No
Unsure
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred Contact Method
*
Please Select
Phone
Email
Either - No Preference
Question Topic
*
Please Select
Advertising/Sponsorships
Advocacy, Government Relations, Public Policy or Legislative Action
COVID
Event/Registration Support
Foundation Home Care Grant
HHA Exchange - EVV/Claims/Portal
Other
Other - EVV/Claims
Regulatory - CDC (TB Screenings)
Regulatory - CGS/CMS
Regulatory - Department of Health
Regulatory - Managed Care Organizations
Regulatory - ODP
Regulatory - OLTL
Regulatory - Other
Sandata - EVV/Claims
Workforce Development & Recruitment
Description of Question or Issue
*
TIN or EIN
*
HHA Exchange Ticket Number(s)
*
Please include the ticket number for your issue in the field above.
Date of Response
*
-
Month
-
Day
Year
Provide the date of HHA Exchange's response to your inquiry above.
Hour Minutes
AM
PM
AM/PM Option
PHA Time to Research/Respond
*
Please Select
Less than 5 minutes
5 minutes
10 minutes
15 minutes
20 minutes
30 minutes
45 minutes
1 hour
1 hour plus
Estimated amount of time our staff would need to allocate for research on this issue.
Mode for Response
*
Please Select
Phone
Email
Both
Summary of Response
*
Submit
Should be Empty: