Appendix A: Sample ACCESS Card (MA)

RECIP or ID#

Nine-digit eCIS Individual Number and one-digit validation number now used by medical providers and other authorized providers such as MA Transportation providers to identify individual eligibility and to bill the Department for services.

NAME:

Name of individual as displayed on eCIS Individual Inquiry Screen.

CARD ISSUE #

Number assigned to each card for security purposes by the Eligibility Verification System (EVS). This number is randomly assigned and not in sequential order. The card issue number is voided by issuance of a replacement card.

SIGNATURE PANEL

(yellow card only)

The blue signature stripe is tamper proof. Individuals should not erase signature. Individuals should sign card for their own protection. Recipients age 18 or over, or under 18 and head of household should sign card. Children may sign if they wish.

MISUSE OR ABUSE OF THIS CARD MAY MAKE YOU LIABLE FOR CIVIL ACTION AND/OR CRIMINAL PROSECUTION

Warning statement to individual.

1-800-932-0582

Fraud and Abuse Hotline.

RETURN ADDRESS
Department of Human

Services
Harrisburg, PA 17105

Note:

This address is for the general public to return lost cards to Harrisburg. The address is not for providers, individuals, or CAO staff to return cards and other mail to Harrisburg. Regular reporting procedures are used to return mail and to report changes.

Even if you or people you are financially responsible for do not obtain services using your ACCESS Card, benefit payments could be made on your behalf or their behalf.  If you fail to report changes timely, you may be required to repay these benefits.