Long-Term Care Handbook Forms

FIRM 176 K

Agreement and Authorization to Pay Claim

(Spanish)

HS 176 KM

Agreement and Authorization to Pay Medical Assistance Claim

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

MA 51

Instructions for Completing MA-51 Medical Evaluation

MA 103

Long Term Care Admission Discharge Transmittal

MA 372

MA 373

Election of Hospice Care

(Spanish)

MA 374

Change of Hospice Provider

MA 375

Revocation of Hospice Care

(Spanish)

MA 376

Pennsylvania Preadmission Screening Resident Review (PASRR)

MA 401

Admissions Notice Packet

OIG 173

Reimbursement Referral

OSIG 189

OIG 609

Long Term Care Investigation Action Report

OIG 613

PA 1 D

Application for Domiciliary Care Supplement

PA 4

Authorization for Release of Information

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

PA 4 LTC

Long Term Care Facility Authroization Form for Release of Information

PA 76

Request for Financial Information

PA 162

PA 162VR

Income Verification Request

PA 189

Overpayment Referral Data Input Form

PA 600

Application for Benefits

(Spanish) (Chinese) (Russian) (Vietnamese) (Cambodian) (Haitian Creole)

PA 600L

Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services

(Spanish) (Chinese) (Russian) (Vietnamese) (Cambodian) (Arabic)

PA 600R

Benefits Review Form

(Spanish) (Russian) (Vietnamese) (Arabic) (Cambodian) (Chinese) (Haitian Creole)

PA 761

Application for Personal Care Home Supplement

PA 1001

ARRC Claim Change Form

PA 1572

Resource Assessment Form

(Spanish)

PA 1666

Criminal History Inquiry

(Spanish) (Chinese) (Russian) (Vietnamese)

PA 1768

Home and Community Based Services (HCBS) Eligibility/Ineligibility/Change Form

PA 1781

Letter to the Social Security Administration

PA 1826

Long Term Care Service Provider Authorization Form

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

PA 1827

Application for Undue Hardship Waiver

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

PA 1827E

Application for Undue Hardship Waiver—Excess Home Equity 

(Spanish) (Arabic)

PA 1829

Voluntary Withdrawal Form

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

PA 1847

Certification of Payment of Income to Community Spouse or Child

PA 1854

Explanation of the Effect of Transfers of Assets on Eligibility for Payment of Long Term Care Services

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

PA 1855

Undue Hardship Waiver (UHW) Decision Form

PA 1856

Parties' Findings of Fact and Stipulated Agreement

PA 1857

Parties' Findings of Fact and Stipulated Agreement for Excess Resources

PA 1886

Certification of Transfer of Resources to the Community Spouse

PA 1887

Results of Resource Assessment

PUB 332

Medical Assistance Estate Recovery Program and Related Topics Questions and Answers

(Spanish)

UB 04

Pennsylvania PROMIESe Provider Handbook