compass. If you have a question during non-business hours or prefer to use email, you may email us . Translation services will be provided free of charge. • Please read the entire form. This form is not available for ordering. ىلإ ةجاحب تنك اذإ . If you would like to apply by telephone, call our Consumer Service Center for Health Care Coverage at 1-866-550-4355. Additional questions may be directed to the appropriate Regional Office of Child Development: Central Region (717) 772-7078 or (800) 222-2117 This Medical Assessment Form (PA 635) is needed to determine whether an individual is able to participate in employment and training activities, what treatment plan(s) could help the individual move towards employment, or determine if the individual is a good candidate for disability benefits or is pregnant.state. PA 600 HC-S: Application for Health Care Coverage, Spanish: 50/pk: View PDF: PA 600 L (AS) Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services: 100/pk: View PDF: PA 600 M (AS) Mail-in Application for Payment of Medicare Part B: 50/pk: View PDF: PA 600 P: Application for Benefits: 100/pk Adopt PA Kids - 1-800-585-7926 Facebook DHS Twitter DHS YouTube DHS Instagram DHS Instagram Sec. 3. To renew online, you must identify yourself by entering your Social Security Number, County/Case Record, and Renewal Due Date. MH785A.us. Your County/Case Record and your Renewal Due Date are on the renewal notice.5058-094-008-1 :eniltoH esubA ediwetatS edivorp ot sdnuf emas eht esu ot ainavlysnneP rof redro ni erac lanoitutitsni rof selur diacideM/ecnatsissA lacideM "seviaw" tnemnrevog laredef eht taht tcaf eht morf semoc reviaw eman ehT . Arkoosh, Secretary Page 1 PA 600 L (AS) 1/20 Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services You can also apply online at: www. In the event a hospitalized patient’s application is being taken directly by the staff of the PA 600 R (AS) 7/23 PA CareerLink® - Important Information PA CareerLink® is a program of the Pennsylvania Department of Labor and Industry to help job seekers find jobs. Need help filling out your COMPASS application? Please call the HELPLINE at 1-800-692-7462 between 8:30 a. MH 785B.ap.PA 600 12/16 Pennsylvania Application for Beneits This is an application for cash, health care and SNAP beneits. This is an application for Medical Assistance benefits.m.m.pa. Scans the copy of the PA 162 in the patient’s county assistance office case record. 2.pa.su. Medical Assistance (Medical Assistance) Financial Eligibility Application for Long-Term Care Supports and Services - PA 600L. • Print the requested information in the unshaded sections. A Guide to Victim's Assistance — Learn about the resources available to victims after abuse, neglect, financial exploitation, or other crimes such as domestic violence, sexual assault, simple and aggravated assault, harassment, theft, and homicide.state.S. If you need help translating it, please contact your county assistance office, CAO.

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COMPLETION INSTRUCTIONS - EMPLOYABILITY ASSESSMENT FORM (PA 1663) An individual with a physical or mental disability which temporarily or permanently precludes him or her from any gainful employment may be eligible for General Assistance, GA. Pregnant women.state. With MAWD you can keep Medical Assistance while you work, even if your earnings increase above the limits for other Medical Assistance Form PA 162. View PDF: PA 600 … About DHS. Printable Forms. Get forms and more information from Adult Protective * You can now submit your Pennsylvania Child Abuse History Clearance Request online. However, there is an option: Medical Assistance for Workers with Disabilities (MAWD).* rebmuN ytiruceS laicoS . • If you need help, another person can help you or you can get • Online: www.secnarussa ytefas dna htlaeh dna ,ssecorp eud ,sredivorp deifilauq fo eciohc sa hcus stifeneb dna secivres fo yarra na reffo sreviaW ., Monday through Friday.compass. If the application is approved, medical assistance coverage begins on the date of the signature on the front of the booklet.compass. (example: 123 … Questions? Call the Department of Human Services Helpline, toll-free, at 1-800-692-7462 (1-800-451-5886 for individuals with hearing impairments) or your county assistance office. If you are hearing impaired, call TTY/TTD at 1-800-451-5886. Page 1 PA 600 L (AS) 8/1 Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services You can also apply online at: www. PA 600 WD (AS) 5/20 This is an application for Medical Assistance benefits. Medical Assistance eligibility is grouped by: Modified Adjusted Gross Income (MAGI) Children aged 18 and under. The Labor and Industry staff knows about current labor market conditions and can give you information and resources to help your job To be eligible for Pennsylvania Medicaid, you must be a resident of the state of Pennsylvania, a U. What you … PA 600 BR-S: Breast and Cervical Cancer Prevention and Treatment (BCCPT)Program – Renewal, Spanish *See below.ssapmoc. PA 1960 3/19 CAO NAME & ADDRESS. • Print the requested information in the unshaded sections. In Pennsylvania, a child with a permanent or temporary disability Pennsylvania offers assistance and other services to people and families in need. TTY users should call 1-800-451-5886 • En Español: Si necesita este información en español, llame al teléfono: 1-800-842-2020 PA 600 HC 7/22 Esta es una solicitud de beneficios de salud. MAWD lets Pennsylvanians with disabilities take a fulfilling job, earn more money and still keep their full medical coverage. After the provider’s representative has reviewed the form for completeness, he/she will witness the client’s or representative’s signature on Page 16.us • In person: Visit your local county assistance office • Phone: Call the DHS Helpline at 1-800-842-2020.us. Parents and caretakers of children under 21.. • If you need help, another person can help you or you can get Contact Us. If you need this application in a different language or someone to interpret, please contact your local county assistance office, CAO. person immediately sign and date Page 1 and complete the PA 600.

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pa. Arkoosh Twitter Sec. The County Assistance Office will notify the hospital of eligibility or ineligibility via a copy of the PA 162. Document. To implement these requirements, … Page 1 PA 600 L (AS) 5/20 Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services You can also apply online at: www. If you need help translating it, please contact your county assistance office, CAO.Caseworkers are available at the county assistance office to help you and answer your questions in person or over the phone, if the office is closed to the public. You must also be one of the following: Pregnant, or.us. • Please read the entire form.ةیبطلا ةدعاسملا عفانم ىلع لوصحلل بلط اذه i PA 600 M (AS) 8/19 This is an application for payment of your Medicare premiums, Coinsurance and Deductibles.esubA ecnatsbuS dna htlaeH latneM fo eciffO )c403( sthgiR fo noitanalpxE dna tnemtaerT yratnulovnI rof noititeP no gniraeH fo ecitoN .llib ruoy no detiderc eb ot redivorp leuf/ynapmoc ytilitu eht ot yltcerid tnes tnemyap emit-eno a si tnarg hsac ehT . Physician Certification for Cil S N NAME OF CHILD CHILD’S DATE OF BIRTH ____ / ____ / _____ COUNTY RECORD NUMBER SOCIAL SECURITY NUMBER The above-named individual has been identified as a child with special needs. You can submit applications and renewals at your local county assistance office drop box or online using COMPASS.eciffO ecnatsissA ytnuoC ruoy tcatnoc esaelp ,enilno gniwener tuoba snoitseuq yna evah uoy fI . Notice with Intent to File a Petition for Extendied Involuntary Treatment and Explanation of Rights (304b or 305) Office of Mental Health and Substance Abuse. Application for Medical Assistance for Workers with Disabilities - PA 600WD.state.pa. This form must be completed to document the disability. Application for Health Care Coverage - PA 600HC. The Low Income Home Energy Assistance Program (LIHEAP) helps families living on low incomes pay their heating bills in the form of a cash grant. Language assistance will be provided free of charge.ssapmoc. Arkoosh Facebook SWAN Youtube SWAN Josh Shapiro, Governor Valerie A. Waiver Information. If you need this application in another language or someone to interpret, please contact your local … Page 1 PA 600 L (AS) 8/1 Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services You can also apply online at: … Apply faster online at www. and 4:45 p. Adults ages 19-64 with incomes at or below 133 percent of the Federal Income Poverty Guidelines (FPIG) Family planning services. Households in immediate danger of being without heat can also qualify for crisis grants. national, citizen, permanent resident, or legal alien, in need of health care/insurance assistance, whose financial situation would be characterized as low income or very low income.

 Non-MAGI

.state. Application for Benefits (SNAP, Health Care, Cash Assistance) - PA 600. Our mission is to assist Pennsylvanians in leading safe, healthy, and productive lives through equitable, trauma-informed, and outcome-focused services while being an accountable steward of commonwealth resources.