• If you need help, another person can help you or you can get Contact Us. • Print the requested information in the unshaded sections. To renew online, you must identify yourself by entering your Social Security Number, County/Case Record, and Renewal Due Date. What you … PA 600 BR-S: Breast and Cervical Cancer Prevention and Treatment (BCCPT)Program – Renewal, Spanish *See below. Your County/Case Record and your Renewal Due Date are on the renewal notice. 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. This is an application for Medical Assistance benefits. 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.compass., Monday through Friday.secnarussa ytefas dna htlaeh dna ,ssecorp eud ,sredivorp deifilauq fo eciohc sa hcus stifeneb dna secivres fo yarra na reffo sreviaW .us.compass.m. The name waiver comes from the fact that the federal government "waives" Medical Assistance/Medicaid rules for institutional care in order for Pennsylvania to use the same funds to provide Statewide Abuse Hotline: 1-800-490-8505. 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. Adults ages 19-64 with incomes at or below 133 percent of the Federal Income Poverty Guidelines (FPIG) Family planning services.us. Scans the copy of the PA 162 in the patient’s county assistance office case record. PA 1960 3/19 CAO NAME & ADDRESS. Waiver Information.0202-248-008-1 ta enilpleH SHD eht llaC :enohP • eciffo ecnatsissa ytnuoc lacol ruoy tisiV :nosrep nI • su. This form is not available for ordering. In Pennsylvania, a child with a permanent or temporary disability Pennsylvania offers assistance and other services to people and families in need. View PDF: PA 600 … About DHS. Document. 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. Medical Assistance eligibility is grouped by: Modified Adjusted Gross Income (MAGI) Children aged 18 and under. 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. Non-MAGI. Application for Benefits (SNAP, Health Care, Cash Assistance) - PA 600. ىلإ ةجاحب تنك اذإ . MH 785B.PA 600 12/16 Pennsylvania Application for Beneits This is an application for cash, health care and SNAP beneits. 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. If you have any questions about renewing online, please contact your County Assistance Office.

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us. 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. • Please read the entire form.pa. If you are hearing impaired, call TTY/TTD at 1-800-451-5886. and 4:45 p. The County Assistance Office will notify the hospital of eligibility or ineligibility via a copy of the PA 162.egrahc fo eerf dedivorp eb lliw secivres noitalsnarT . 3.S. Medical Assistance (Medical Assistance) Financial Eligibility Application for Long-Term Care Supports and Services - PA 600L.state. Parents and caretakers of children under 21. If you need this application in a different language or someone to interpret, please contact your local county assistance office, CAO.pa. Printable Forms. The cash grant is a one-time payment sent directly to the utility company/fuel provider to be credited on your bill. Pregnant women. Get forms and more information from Adult Protective * You can now submit your Pennsylvania Child Abuse History Clearance Request online.etats. Language assistance will be provided free of charge. MH785A.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.pa.compass. If you have a question during non-business hours or prefer to use email, you may email us . 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.m. If you would like to apply by telephone, call our Consumer Service Center for Health Care Coverage at 1-866-550-4355.state. Arkoosh Facebook SWAN Youtube SWAN Josh Shapiro, Governor Valerie A. Arkoosh Twitter Sec. 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. • If you need help, another person can help you or you can get • Online: www.AG ,ecnatsissA lareneG rof elbigile eb yam tnemyolpme lufniag yna morf reh ro mih sedulcerp yltnenamrep ro yliraropmet hcihw ytilibasid latnem ro lacisyhp a htiw laudividni nA )3661 AP( MROF TNEMSSESSA YTILIBAYOLPME - SNOITCURTSNI NOITELPMOC . person immediately sign and date Page 1 and complete the PA 600.

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PA 600 WD (AS) 5/20 This is an application for Medical Assistance benefits. Need help filling out your COMPASS application? Please call the HELPLINE at 1-800-692-7462 between 8:30 a.state. If the application is approved, medical assistance coverage begins on the date of the signature on the front of the booklet. 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. Social Security Number *.. Households in immediate danger of being without heat can also qualify for crisis grants. Application for Medical Assistance for Workers with Disabilities - PA 600WD. 2.ssapmoc. • Please read the entire form. 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. 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. 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.ro ,tnangerP :gniwollof eht fo eno eb osla tsum uoY .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. However, there is an option: Medical Assistance for Workers with Disabilities (MAWD). Notice of Hearing on Petition for Involuntary Treatment and Explanation of Rights (304c) Office of Mental Health and Substance Abuse. • Print the requested information in the unshaded sections.state. 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.OAC ,eciffo ecnatsissa ytnuoc ruoy tcatnoc esaelp ,ti gnitalsnart pleh deen uoy fI .pa. This form must be completed to document the disability. MAWD lets Pennsylvanians with disabilities take a fulfilling job, earn more money and still keep their full medical coverage. 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. If you need help translating it, please contact your county assistance office, CAO. 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.CH006 AP - egarevoC eraC htlaeH rof noitacilppA . (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. You can submit applications and renewals at your local county assistance office drop box or online using COMPASS.compass.pa.us. 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.