|
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 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 472CM 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