Pennsylvania Non Skilled Agency Information Form

Note: All fields must be filled out accept where office use only. Anything with a red Asterisk (*) must be filled out. anything with a Asterisk (*) that does not pertain to you acknowlege with Not Applicable (N/A), or Agency to Apply for me (A/A) . Althouthough you may see a short box you can contioune to write.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
What's the best way to contact you?*

EmailPhoneText
AGENCY NAME:*
DBA (if applicable):
Office use (please skip this one question)

Yes \No
For KMA Use only: is the agency name filed with the secretary of state? Please note that any changes to the agency name after the initial secretary of state documents have been filed will be subject to 1) delays in license or accreditation processing, and 2) fees including reprinting policies, amending the name with the secretary of state, amending your name with the state license and/or Medicare. Any changes to the name must be disclosed immediately to your account manager.
AGENCY ADDRESS:*
MAILING ADDRESS:*
AGENCY EMAIL: Agency Email address must be active.*
AGENCY PHONE:*
AGENCY FAX:
CONTACT NAME:*
CONTACT PHONE:*
CONTACT EMAIL:*
TAX ID/EIN Number:*
NPI Number:*
COUNTIES SERVICED:(Must be adjoining from counties physical of location). You can type multiple counties.*
HOURS OF OPERATION:Please note someone must be physically in the office during operating hours.*
Acknowlegement of services needed
I Am A Full Consultant Pa Home care Client

YesNo
I AM A Client For An Application For Pa Home Care ONLY

YesNo
I Am A client that need office AUDIT to get ready for surveyor

YesNo
I Am A client that need a OFFICE SET UP

YesNo
I am a client that need to expand my home care/health care business

YesNo

Page 2 FOR OFFICE USE If you are a client if you KMA to Obtain your NPI number. in the section enter into field (N/A) or (A/A).
SOS LOGINS: QUESTION 1: A // QUESTION 2: B
NPI LOGINS:
NPI / CMS SECURITY: BF/GF: A - FATHER'S MIDDLE: B - FAV FOOD: C - MOTHER'S MAIDEN: D - FIRST PET: E
ACCREDITING BODY LOGINS:
PORTAL LOGINS:
DATE OF COMPANY FORMATION:
OWNERSHIP
OWNER 1:*
OWNERSHIP%:*
HOME ADDRESS:*
PHONE:*
EMAIL:*
SS#:*
DOB:*
PLACE OF BIRTH:*
OWNED, MANAGED OR OPERATED ANY HEALTHCARE FACILITIES?

YesNo
OWNER 2:*
OWNERSHIP%:*
HOME ADDRESS:*
PHONE:*
EMAIL:*
SS#:*
DOB:*
PLACE OF BIRTH:*
OWNED, MANAGED OR OPERATED ANY HEALTHCARE FACILITIES?

YesNo
OWNER 3:
OWNERSHIP%:
HOME ADDRESS:
PHONE:
EMAIL:
SS#:
DOB:
PLACE OF BIRTH:
OWNED, MANAGED OR OPERATED ANY HEALTHCARE FACILITIES?

YesNo
OWNER 4:
OWNERSHIP%:
HOME ADDRESS:
PHONE:
EMAIL:
SS#:
DOB:
PLACE OF BIRTH:
OWNED, MANAGED OR OPERATED ANY HEALTHCARE FACILITIES?

YesNo
Board of Directors
You will need at least 2 people, but they may have multiple titles. Fill all roles.
PRESIDENT:*
PHONE:*
DOB:*
SS #:*
HOME ADDRESS:*
VICE PRESIDENT:*
PHONE:*
DOB:*
SS #:*
HOME ADDRESS:*
SECRETARY:*
PHONE:*
DOB:*
SS #:*
HOME ADDRESS:*
TREASURER:*
PHONE:*
DOB:*
SS #:*
HOME ADDRESS:*
KEY STAFF INFORMATION
ADMINISTRATOR:*
HOME ADDRESS:*
PHONE:*
DOB:*
SS #:*
EMAIL:*
ALTERNATE ADMINISTRATOR:*
HOME ADDRESS:*
PHONE:*
DOB:*
SS #:*
EMAIL:*
WHO WILL BE RESPONSIBLE FOR OVERALL BUSINESS DIRECTION?*
WHO WILL BE RESPONSIBLE FOR OVERALL MANAGEMENT AND OPERATIONS OF THE FACILITY?*
By checking this box, I acknowledge the above electronic signature as a full acceptance of the terms above.*

Signature
In order to begin your state license application,
we will need the following documents from you.
Articles of Formation/Incorporation. If you have not filed for your articles of incorporation yet, as a courtesy, we can obtain these for you. The cost you will need to pay to the State of Pennsylvania is $125 which is a 3rd party fee and not included within your contract. The ASSUMED· NAME (dba) is optional, this is an additional $70 fee.*

YesNo
If , Yes and you have this document upload below

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Proof of EIN. We will need a copy of the document sent to you by the IRS when you applied for your EIN. The name on this document must match your Articles exactly. If you have not obtained an EIN yet, as a courtesy, we can obtain this for you.*

YesNo
If , Yes and you have this document upload below

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Proof of NPI. This will generally be the email sent to you assigning you an NPI. The name on your proof of NPI must match your Articles exactly. If you do not have an NPI, as a courtesy, we can obtain one for you.*

YesNo
If , Yes and you have this document upload below

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Resumes in Microsoft Word format for your Owners, Administrator and Alternate Administrator. The resumes must include full names, dates of employment, and addresses for previous employers. Templates are available online for proper formatting.*

YesNo
If , Yes and you have this document upload below

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Criminal Background Checks for Owners and Administrators will need to be completed. DO NOT COMPLETE BACKGROUND CHECKS WITHOUT INSTRUCTION FROM YOUR ACCOUNT MANAGER!!*

YesNo
If , Yes and you have this document upload below

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Copy of Driver’s License (front only) or other proof of PA residency for all administrators.
Copy of Driver’s License (front only) or other proof of PA residency for ADMINISTRATOR*

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Other proof of residency If, applicable

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Copy of Driver’s License (front only) or other proof of PA residency for ALTERNATE ADMINISTRATOR*

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Other proof of residency If, applicable

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Do you have your Policies*

YesNo
If Yes, please upload

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Once we have received all the above listed documents, we will be
able to begin the process of completing your license application.
I am aware that once I have submitted all necessary documents to Keitt Media Agency as my consultant firm it will take 2‐4 weeks for my application to be completed. I further recognize that any changes made to this information, which require an application to be amended, are also subject to a 2‐4 week timeline for completion. I have read the statement above and by signing below, I accept the terms as written. By checking this box, I acknowledge the above electronic signature as a full acceptance of the terms above.*

Signature Acknowledgement
I am aware that once I have submitted all necessary information to Keitt Media Agency as my consultant firm it will take approximately 8 weeks for my policies and procedures to be completed. I further recognize that any changes made to this information (name change, demographics change, logo change), which require policies to be amended, are subject to additional fees for which I will be solely be responsible for. I have read the statement above and by signing below, I accept the terms as written.*

Signature Acknowledgement
Upon completion of this form, you will be notified by a KMA representative.
I attest that the information within this document is accurate and acknowledge that it will be entered into my application documents exactly as written below.I acknowledge there could be an additional wait in the event this information changes.
Signature*

Clear
Please verify that you are human*
If you have any questions please ask you, admins, first! Click the drop-down below.
Question please email our admins.
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Consultant Retainer $2,500.00
We are excited to kickstart our collaboration with you at Keitt Media Agency (KMA). To begin working on your customized package of services, we kindly request that you submit the consultant retainer fee of $2500.00. Your journey with us starts by completing the intake form, where you'll provide us with valuable insights into your specific needs and goals. Based on the information you provide, we will tailor a package that aligns perfectly with your requirements. After this, the remaining payment details will be outlined in an invoice for your convenience. Please proceed with the payment of the retainer fee at your earliest convenience. Once received, we'll swiftly dive into crafting a comprehensive strategy that suits your unique needs. We are committed to delivering results that exceed your expectations. Thank you for choosing KMA as your partner. We are excited about what lies ahead and look forward to working closely with you.

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