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PA Independent Enrollment Broker fax number
(888) 349-0264
PA Independent Enrollment Broker (PA IEB)
Used for: Submitting Physician Certification Form (MA 570) for Medicaid Home and Community Based Services (HCBS) eligibility under the PA IEB; fax to 1-888-349-0264.
Fax destination details
- Department
- PA Independent Enrollment Broker (PA IEB)
- Purpose
- Submitting Physician Certification Form (MA 570) for Medicaid Home and Community Based Services (HCBS) eligibility under the PA IEB; fax to 1-888-349-0264.
- Form
- MA 570 — Physician Certification Form
- Address
- P.O. Box 61560, Harrisburg, PA 17106
- Voice phone
- 1-877-550-4227
- Website
- Visit organization website
Before you send
- Confirm that this exact department handles your document or request.
- Check the organization website or call its main line for the current fax number.
- Include a cover sheet and any case, member, claim, or form reference required.
- Keep the delivery confirmation with your submission records.
Physician completes patient information, diagnoses, and level of care; must be signed by an MD/DO; submit the form to PA IEB via fax within five business days of receipt.
Official form instructions are published as a downloadable file on the organization's website.
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