|
Packet # |
2 |
4 |
5 |
6 |
7 |
8 |
|
Packet Type |
SNAP with MA |
GA or SSI Related MA |
MAGI or TANF Related MA |
Cash |
Cash with SNAP |
SLMB Only |
|
Interview Type |
Phone (D) |
Mail (D) |
Mail (D) |
Face-to-Face (D) |
Face-to-Face (D) Phone (X) Mail (X) |
Mail (D) |
|
Forms |
PA600R |
PA600R |
PA600HC |
PA600R |
PA600R |
PA600M |
|
PA253CLR |
PA253CLR |
PA253CLR |
PA253CLR |
PA253CLR |
PA253CLR |
|
|
PA4* |
PA4* |
PA4* |
PA-4* |
PA4* |
PA4* |
|
|
PA253R |
PA253R |
PA253R |
PA253R |
PA253R |
PA253R |
|
|
PA10SFSP |
|
|
|
PA10SFSP |
|
|
|
PA1795* |
|
|
|
PA1795* |
|
|
|
PA1530* |
|
|
|
|
|
|
|
PA635* |
PA1796* |
PA1796* |
PA1796* |
|
PA1796* |
|
|
PA772* |
|
PA635* |
PA635* |
PA635* |
|
|
|
|
|
|
|
PA772* |
|
|
|
PA1809* |
PA1809* |
PA1809* |
PA1809* |
PA1809* |
PA1809* |
|
|
PA1819* |
PA1819* |
PA1819* |
PA1819* |
PA1819* |
PA1819* |
|
|
PA1663** |
PA1663** |
|
PA1663** |
PA1663** |
|
|
|
PA1664** |
PA1664** |
|
PA1664** |
PA1664** |
|
|
|
PA1666** |
PA1666** |
|
PA1665** |
PA1665** |
|
|
|
PA1671** |
PA1671** |
|
PA1671** |
PA1671** |
|
|
Packet # |
9 |
10 |
12 |
|
Packet Type |
MAWD Only |
BCCPT |
PH95 Only |
|
Interview Type |
Mail (D) |
Mail (D) |
Mail (D) |
|
Forms |
PA600WD |
PA600BR |
PA600HC |
|
PA253CLR |
|
PA253CLR |
|
|
PA4* |
|
|
|
|
PA253R |
PA253R |
PA253R |
|
|
PA1796* |
|
|
|
|
PA1809* |
|
PA1809* |
|
|
PA1819* |
|
PA1819* |
(D) This interview type is the Default for this packet.
(O) This interview type is an Option for this packet.
(X) This interview type is NOT an option for this packet.
* Optional forms
**Optional GA-related forms
|
Form Name |
Form Description |
|
INSTRSH |
Instruction Sheet (Included in all packets) |
|
PA253CLR (T,F,M)* |
Cover Letter |
|
PA4 |
Authorization for Release of Information |
|
PA253R (T,F,M)* |
Appointment Notice and Verification Checklist |
|
PA10SFSP |
Notice of Expiration of Certification |
|
PA772 |
E&T Rights and Responsibilities |
|
PA1663 |
Employability Assessment Form |
|
PA1664 |
Employability Re-Assessment From |
|
PA1665 |
Criminal History Inquiry |
|
PA1666 |
Criminal History Inquiry (GA-Related MA Only) |
|
PA1671 |
Health-Sustaining Medication Assessment Form |
|
PA1795 |
Household Members/ Living expenses |
|
PA1796 |
Household Composition Verification Statement |
|
PA1530 |
Job Readiness Assessment |
|
PA1595 |
Telephone Interview Instructions |
|
PA635 |
Medical Assessment Form |
|
PA600WD |
Mail in Application for MA For Workers with Disabilities |
|
PA600R |
Benefits Review |
|
PA600M |
Mail in Application for Payment of Medicare Part B Premium |
|
PA600L |
Medical Assistance (Medicaid) LTC |
|
PA600HC |
Application for Healthcare Coverage |
|
PA600BR |
Breast and Cervical Cancer |
|
PA1809 |
Citizenship and Identity Information |
|
PA1819 |
Affidavit Attesting To Identity Of Minor Child |
|
* T = Telephone / F = Face-To-Face / M = Mail |
|
Updated April 20, 2017, Replacing February 14, 2012