Appendix B: Medical Assistance Automated Renewal Forms

Packet #	2	4	5	6	7	8
Categories	SNAP with MA	SSI-related MA GA-related MA	TANF-related MA MAGI-related MA	Cash Cash with MA	Cash with SNAP/MA	Buy-In Only
Renewal Form	PA 600R	PA 600 or PA 600HCR	PA 600HCR	PA 600R	PA 600R	PA 600M
Mandatory Forms	PA 1903 PA 253RTC (Telephone) OR PA 253 CLRF/PA 253RF (Face to Face) PA 10SFSP PUB 567.1 PA 772 PA 1841 CM 472 CM 506 NVRA	PA 1903 PA 253RM CM 472 CM 506 NVRA	PA 1903 PA 253RMM CM 472 CM 506 NVRA	PA 1903 PA 253CLRF/PA253RF(Face-to-Face) PA 253CLRT/PA253RT (Telephone) CM 472 CM506 NVRA	PA 1903 PA 253CLRF/PA253RF(Face-to-Face) PA 253CLRT/PA253RT (Telephone) PA 10SFSP PUB 567.1 PA 772 CM 472 CM 506 NVRA	PA 1903 PA 253RM CM 472 CM 506 NVRA
Optional Forms	PA 635 PA 1795 GA-related MA: PA1663 PA1665 PA1666 PA1671	PA 1796 GA-related MA: PA1663 PA1665 PA1666 PA1671	PA 635 PA 1796 GA-related MA: PA1663 PA1665 PA1666 PA1671	PA 635 PA 1796 GA-related MA: PA1663 PA1665 PA1666 PA1671	PA 635 PA 1795 PA 1841 GA-related MA: PA1663 PA1665 PA1666 PA1671	PA1796

Packet #	9	10	12	17
Title	MAWD Only	BCCPT	PH95 Only	Former Foster Care MA
Renewal Form	PA 600WD	PA 600BR	PA 600HCR	PA 1933
Mandatory Forms	PA 1903 PA 253RM CM 472 CM 506 NVRA	PA 253BCCPT CM 472 CM 506 NVRA	PA 1903 PA 253RMM CM 472 CM 506 NVRA	PA 1903 PA 253RMM CM 472 CM 506 NVRA
Optional Forms	PA 1796	N/A	PA 1796	PA 635 PA 1796

Form Number	Description
CM 472	Notice of Privacy Practices
CM 506	Voter Registration Cover Letter
NVRA	Voter Registration Form
PA 4	Authorization for Release of Information
PA10SFSP	Notice of Expiration of Certification
PA 253BCCPT	Notice of Benefit Renewal – Breast and Cervical Cancer Treatment
PA 253CLRF	Notice of Benefit Renewal – Face-to-Face Interview
PA 253CLRT	Notice of Benefit Renewal – Telephone Interview
PA 253ESAP	SNAP Elderly or Disabled Renewal Information
PA 253RF	Renewal Information List – Face-to-Face Interview
PA 253RM	Medical Assistance Renewal Information Combined Form: Income and Resource Information
PA 253RMM	Medical Assistance Renewal Information Combined Form: Income Information
PA253RT	Renewal Information List – Telephone Interview
PA 253RTC	Benefits Renewal Information Combined Form
PA 600BR	Breast and Cervical Cancer Prevention and Treatment Program (Renewal)
PA 600 HCR	Application for Health Care Coverage
PA 600L	Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services
PA 600M	Application for Payment of Medicare Premiums, Coinsurance and Deductibles
PA 600R	Benefits Review
PA 600WD	Application for Medical Assistance for Workers with Disabilities
PA 635	Medical Assessment Form
PA 772	Employment and Training Program Rights and Responsibilities
PA 1663	Employability Assessment Form
PA 1664	Employability Re-Assessment Form
PA 1665	Criminal History Inquiry
PA 1666	Criminal History Inquiry (GA-Related MA Only)
PA 1671	Health-Sustaining Medication Assessment Form
PA 1795	Household Members/Living Expenses
PA 1796	Household Composition Verification Statement
PA 1809	Citizenship and Identity Information
PA 1819	Affidavit Attesting to Identity of Minor Child
PA 1841	Work Requirements for Receipt of Food Stamp Benefits
PA 1903	Benefit Renewal Notice
PA 1921	ABAWD Time Limit Medical Exemption Form
PUB 567.1	Help for Pennsylvanians in Need

Completely revised January 23, 2020, Replacing April 20, 2017