Appendix A: Retention Periods for Specific Documents

The following documents should be retained either in the original paper form in the case record or as an electronically scanned document for a period of six (6) years from the date of its creation or the date it was last in effect, whichever is later.

All PA 600 series forms Application for benefits (PA 600, PA 600-S, PA 600R, PA 600AAB etc.)

MA 51

Medical Evaluation Form

MA 103

Admission/Discharge/Transmittal Form

PA 1768

Home and Community Based Services Eligibility/Ineligibility/Change Form

PA/CS 173

WP Support and Good Cause Notice

PA/CS 173

GC Good Cause Determination

FAIR 293

Child Support Action Notice

PA/CS 611

Acknowledgement of Paternity

PA/CS 643A

Certification of Cooperation

PA 564

Semiannual Reporting Form

PA 564A

Late/Incomplete Notice

PA 586

Report of Physical/Mental Examination

PA 162

series Manual notices (see information related to sanctions below)

PA/FS 163

Notice of Denial of Expedited Services

HS 764

Authorization/Instruction Sheet (Retain for benefit issuance and controlled documents authorization only)

PW 764.1

Individual Add-On

HS 1815

Authorization for Use or Disclosure of Personal Information

PA 635

Medical Assessment Form

PA 1663

Employability Assessment Form

PA 1664

Employability Reassessment Form

PA 1671

Health Sustaining Medication Form

PA 1672

Drug and Alcohol Treatment Information Form

PA 731

Disability Advocacy Program Referral

PA 772

E&T Program Rights & Responsibilities

PA 78

Request for Employment Information

MA 112

Newborn Eligibility Form

I-94’s

Alien/Refugee documentation

PA 189

Overpayment Referral Data Input Form

FAIR 581

Food Stamp Program Disqualification

PA 1564

Referral to the Social Security Administration

PA 1661

Agreement of Mutual Responsibility (see information related to sanctions below)

PA 1665

Criminal History Inquiry

PA 1591

Child Care Provider Information Sheet

PA 1583

Verification of Child Care Costs

PA 1695

Immunization Certification

PA 1699

Child-Care Worksheet

PA 1701

Post-24 Month Compliance Review

PA 1714

TANF Benefits Received Outside of PA

PA 1727

Verification for Time-Out Based on Domestic Violence

PA 1747

Domestic Violence Verification Form

PA 207

Request for Investigation of Check

PA 239SP

Food Stamp Change Report Form

PA 1572

LTL Resource Assessment

PA 1809

Citizenship and Identity Information

PA 1817

Affidavit Attesting to Unavailability of Documentary Evidence or Citizenship

PA 1819

Affidavit Attesting to Identity of Minor Child 2

PA 176NR

Agreement to Dispose of Non-Resident Real Property

HS 176KM

Agreement and Authorization to Pay Medical Claim

FIRM 176K

Agreement and Authorization to Pay Claim

OIG 173

Reimbursement Referral

OIG-176

SSIAuthorization for Reimbursement of Assistance

All HIPAA client documents and our responses to HIPAA inquiries, complaints, HIPAA disclosures that are subject to HIPAA disclosure tracking requirements, requests for restrictions and our responses to those requests, requests for amendment, lists of records clients may access.

All information related to a sanction must be maintained in the record indefinitely. This documentation includes:

Any verification or corroborating Good Cause (GC) evidence the client may have provided or was in the record and used to determine GC by the caseworker.

The following documents only need to be retained in the case record until the next completed renewal and/or update.

Some documents only need to be retained in the case record until the information is updated in the eCIS. Some examples:

Reissued July 9, 2019 , replacing February 23, 2017