Appendix E: PA 600 Series Application Forms

PA 600

Common Application Form

PA 600-S

Common Application Form (Spanish)

PA 600HC

Application for Health Care Coverage

PA 600HC-S

Application for Health Care Coverage (Spanish)

PA 600L

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

PA 600L-S

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

PA 600M

Mail-In Application for Payment for Medicare Part B Premium

PA 600M-S

Mail-In Application for Payment for Medicare Part B Premium (Spanish)

PA 600P

Application for Benefits (with Provider Addendum)

PA 600WD

Medical Assistance for Workers with Disabilities

PA  600WD-S

Medical Assistance for Workers with Disabilities (Spanish)