|
Form/Publication Number |
Form/Publication Name |
| We have included a voter registration application for with this letter. (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Request For CAO Action | |
| Application For Initial Determination For Title IV-E Eligibility And Medicaid Determination | |
| Minor Or Non Minor Dependent Parent/Child Foster Care Information | |
| Pennsylvania Voter Registration Application | |
| Agreement & Authorization To Pay Claim (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Document Verification Request Form | |
| Document Verification Request Form | |
| Agreement & Authorization to Pay Medical Assistance Claim (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Standard Transmittal | |
| Authorization/Instruction Sheet | |
|
Commonwealth of Pennsylvania, Department of Human Services Authorization for Use or Disclosure of Personal Information (Spanish) |
|
| Reimbursement Referral | |
| Authorization For Reimbursement of Interim Assistance Initial Claim or Post Eligibility Case (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) | |
| Agreement for Repayment Delayed UC Checks (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Overpayment Referral | |
| Food Stamp Overpayment Computation Sheet | |
| Authorization for Release of Information (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Medical Assistance Temporary Access Card | |
| Computation Sheet | |
| Report of Ophthalmological Examination | |
| Protective Payee's Account | |
| Request For Financial Information | |
| Request for Employment/Earnings Information | |
| Request for Employment/Earnings Information | |
| Request for Insurance Data | |
| Burial Payment Request | |
| Request for Address and/or Amount of Assistance | |
| Overpayment Referral Data Input Form | |
| Assignment of Interest in Decedent's Estate | |
| Supplemental Nutrition Assistance Program Change Report | |
| Returned Check Transmittal | |
| Semiannual Reporting Form (Spanish) | |
| Pennsylvania Application for Benefits (Spanish) (Chinese) (Russian) (Vietnamese) (Cambodian) (Haitian Creole) (Arabic) (French) | |
| Benefits Review (Spanish) (Russian) (Vietnamese) (Arabic) (Cambodian) (Chinese) (Haitian Creole) | |
| Medical Assessment Form (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| DAP Referral Form (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Data Entry Form | |
| DAP Disability Report | |
| You May be Eligible for Social Security Disability Benefits | |
| DAP Contact Card | |
| Medical Review Team Transmittal | |
| Offset Over Issuance Against Restored Benefits | |
| Public Housing Authority Voluntary Vendor Payment Referral Form | |
| Public Housing Authority Voluntary Vendor Payment Program Amended Referral Form | |
| PA 905V | Voluntary Vendor Payment Request Form |
| Referral to the Social Security Administration | |
| Document Verification Request | |
| Disbursement and Corresponding Dates for CASH/SNAP Benefits | |
| Voter Registration Questions (Spanish) | |
| Agreement of Mutual Responsibility (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) (Nepali) | |
| Employability Assessment Form (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Employability Re-assessment Form (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Income Calculation Worksheet for Initial IV-E Eligibility | |
| Receipt of State Supplementary Payment (SSP) | |
|
HIPAA Disclosure Tracking System Disclosure Request Data Entry Form |
|
| Request for Restrictions on the Use and Disclosure of Protected Health Information | |
| Complaint (Spanish) | |
|
Request for Alternative Means or Location of Communication |
|
| Request for Amendment of Health Information | |
| Request to Access, Inspect, or Obtain a Copy of Protected Health Information | |
| Notices of Privacy Practices (Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian) | |
| Request for Accounting of Disclosures | |
| Desk Guide Timely Appeals | |
| Receipt of Payment | |
| Advance Notice | |
| Advance Notice | |
| Confirming Notice | |
| What's the First Step? (Spanish) | |
| Burial and Cremation Benefits | |
| Withdrawal Cover Sheet | |
| Controlled Document Order and Report | |
| Temporary Medical Assistance Access Card Record Log | |
| Issuing Officer's Control Document Log | |
| Temporary Medical Assistance Access Card Record Log | |
| Issuing Clerk's Control Document Log | |
| Authorization/Instruction Sheet | |
|
Administration for Children and Families U.S. Repatriation Program Non-Emergency Monthly Financial Statement Form |
|
|
U.S. Repatriation Program Privacy and Repayment Agreement Form |
|
|
U.S. Repatriation Program Refusal of Temporary Assistance Form |