Form/Publication Number |
Form/Publication Name |
| Earned
Income Tax Credit
(Spanish) |
|
| Report
of Suspected Child Abuse
(Spanish) |
|
| Payroll Deduction Discontinuance Letter | |
| Agreement
and Authorization to Pay Claim
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Agreement
and Authorization to Pay Medical Assistance Claim
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Authorization/Instruction Sheet | |
| Instructions for Completing MA 51 Medical Evaluation | |
| Outpatient Services Authorization Request | |
| Dental Prior Authorization Request | |
| Long Term Care Admission and Discharge Transmittal | |
| Newborn Eligibility Form Instructions | |
| Eligibility Determination Form | |
| Administrative Waiver Request Form | |
| Presumptive Eligibility Application | |
| Certification of Terminal Illness | |
| Election of Hospice Care | |
| Change of Hospice Provider | |
| Revocation of Hospice Care | |
| Reimbursement Referral | |
| Overpayment Referral | |
| Application for Domiciliary Care Supplement | |
| Authorization
for Release of Information
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Medical Assistance Temporary Access Card | |
| Request for Financial Information | |
| Request for Employment/Earnings Information | |
| Request for Legal Information | |
| Request for Insurance Data | |
| Receipt for Payment of Child Care | |
| Notice of Medicaid Eligibility for SSI Recipient | |
| Notice | |
| Information Obtained With Your Social Security Number | |
| Appointment Notice and Verification Checklist | |
| Instruction for Physician/Licensed Psychiatric Clinic in Completing Report of Physical/Mental Examination | |
| Pennsylvania
Application for Benefits
(Spanish) (Chinese) (Russian) (Vietnamese) (Cambodian) |
|
Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program Medicaid Eligibility Application |
|
Breast and Cervical Cancer Prevention and Treatment Program Renewal (Spanish) |
|
| Application
for Health Care Coverage
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Application
for Health Care Coverage
(Spanish) |
|
Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Supplement to the PA 600 L | |
Application for Payment of Medicare Premiums, Coinsurance, and Deductibles (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Provider Application for Benefits | |
| Benefits
Review
(Spanish) |
|
Application for Medical Assistance for Workers with Disabilities (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Supplement to the PA 600 WD | |
| Medical
Assessment Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| DAP
Referral Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| State Supplement for Domiciliary Termination | |
| Authorization for State Supplement for Persons in a Domiciliary Care Facility/Personal Care Home | |
| Medical Review Team Transmittal | |
| Application for Personal Care Home Supplement | |
| Corrective Action Paid Medical Expense Reporting Form | |
| Employability
Assessment Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Employability
Re-Assessment Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Health
Sustaining Medication Assessment Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Drug
and Alcohol Treatment Information Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Initial
Premium Statement
(Spanish) |
|
| Premium Statement | |
| MAWD
Self-Employment Verification Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Home and Community Based Services (HCBS) Eligibility/Ineligibility/Change Form | |
| SSI Income Stopped | |
| Special SSI Recipient Status | |
| Information Affecting Eligible SSI Recipient | |
| Apply for SSI for Child Over 18 | |
| Remaining Eligible for Medicaid | |
| Do
You Need Help With Your Phone Bill?
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Citizenship
and Identity Information
(Spanish) |
|
| You
Recently Applied for Medicaid Benefits and Have Declared U.S.
Citizenship
(Spanish) |
|
| You
are Currently Receiving Medicaid Benefits and Have Declared U.S.
Citizenship
(Spanish) |
|
| You
are Currently Receiving Medicaid Benefits and Have Declared U.S.
Citizenship
(Spanish) |
|
| Replacement
Birth Certificate
(Spanish) |
|
| Affidavit
Attesting to Unavailability of Documentary Evidence of Citizenship
(Spanish) |
|
| Affidavit
Attesting to Citizenship
(Spanish) |
|
| Affidavit
Attesting to Identity of Minor Child
(Spanish) |
|
Request For Certificate of Health Coverage |
|
| Certificate of Health Coverage | |
| Voluntary
Withdrawal Form
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Delay in Buy-In Enrollment | |
| Referral to Social Security Administration | |
| State Correctional Institution Inpatient Eligibility Form | |
| County Prison Inpatient Eligibility Form | |
Physician Certification for Child with Special Needs (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Medical Assistance Closure Checklist | |
| Acknowledgement
of Paternity
(Spanish) |
|
| Notice to Applicant | |
| Advance
Notice
(Spanish) (Chinese) |
|
| Confirming
Notice
(Spanish) |
|
| Your
Right to Appeal and to a Fair Hearing
(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) |
|
| Civil Rights Enforcement Complaint Form | |
| Notification Check was Returned for Insufficient Funds |