Pennsylvania Code › Title 55 - HUMAN SERVICES › Part II - Public Assistance Manual › Subpart A - Assistance Policies and Procedures › Chapter 101 - GENERAL PROVISIONS › Section 101.5 - Forms

Current through Register Vol. 54, No. 28, July 13, 2024
(a) Forms used in
				  the administration of the public assistance program, including those which may
				  be revised or renumbered are available from the Department of Human Services,
				  Management Services, Post Office Box 2675, Harrisburg, Pennsylvania
				  17105.
(b) The following is a list
				  of several forms referred to on this part and their corresponding official
				  designations:
A-3
-Treasury Investigation Form.
A-4
-Treasury Investigation Report Form.
AG-1
-Notice of Exception.
AG-1 Part I
-Identification Factors.
AG-1 Part II
-Eligibility Factors.
AG-1 Part III
-Explanation of Exception.
CY 931
-Certificate of Subsidized
					 Adoption.
DP 207
-Request for Treasury
					 Investigation.
DHS 6190
-Authorization to Sign Document.
ES 1
-Referral and Placement Report.
ES 350
-Applicants' Record Card.
IM-2
-IM Referral to Vocational
					 Rehabilitation.
IM-3
-Referral for WIN Registration.
IM-6
-AFDC WIN Change Notice.
IM-9
-AFDC WIN Grant Reduction Record.
MA S-95
-WIN Registration Record.
MA 5-96
-WIN Certification Record.
MA 5-97
-WIN Status Change Notice.
MA 57
-Hospital Admission Certification.
MA 62
-Social Information for Permanent and
					 Total Disability.
MA 215
-Letter-Disability Review.
OA-132
-Accounting for Appropriation
					 Advancement Voucher Transmittal.
OA 275
-Authorization of Signature Card.
PA 1
-Application for Assistance.
PA 1-M
-Application-Medical Assistance.
PA 1-MS
-Supplemental Application for
					 Medical Assistance.
PA 1-S
-Supplemental Application for
					 Medical Assistance.
PA 1-SP
-Application for Participation in
					 Food Stamp Program.
PA 3-R
-Property Lien Notice.
PA 4
-Authorization for Information on
					 Resources.
PA 4-M
-Medical Assistance Physician's
					 Prescription.
PA 5A
-Medical Identification Card
					 (White).
PA 5-A
-Medical Identification Card
					 (Blue).
PA 5-B
-Medical Identification Card
					 (Pink).
PA 5-C
-Medical Identification Card
					 (Green).
PA 5-M
-Certification-Medical Care.
PA 6-F
-Assignment of Insurance.
PA 6-G
-Distribution of Insurance
					 Benefits.
PA 6-K
-Assurance as to Nonchange of
					 Beneficiary.
PA 6-M
-Hospital Admission Certification.
PA 9
-Reimbursement Agreement.
PA 13
-Reference Card and Registration
					 Report.
PA 21
-Face Sheet.
PA 21-B
-Blind Pension Authorization
					 Sheet.
PA 21-BI
-Computation Sheet.
PA 21-BN
-Federal-State Blind Pension
					 Authorization Sheet.
PA 21-F
-Legally Responsible Relatives.
PA 21-H
-Insurance-Burial Resources.
PA 21-I
-BP Property.
PA 21-M
-Computation of Resources Medical
					 Assistance.
PA 21-MR
-Benefit Period Record.
PA 21-MU
-Medical Assistance Verification
					 Summary.
PA 21-N
-NHC Authorization Sheet.
PA 21-P
-Authorization Sheet.
PA 21-PF
-Foster Care Authorization
					 Sheet.
PA 28
-Analysis of Employment
					 Information.
PA 28-S
-Employable Index Card.
PA 40
-Report of Epthamological
					 Examination.
PA 41
-Report of Medical Examination.
PA 41-D
-Report of Medical
					 Examination-Domiciliary Care.
PA 41-S
-Medical Supplement.
PA 44
-Burial Reserve Agreement.
PA 48
-Authorization for Services and
					 Supplies.
PA 50
-Request for Appointment of Guardian,
					 Representative, or Trustee.
PA 50-P
-Agreement (Public Nursing Home
					 Care Program).
PA 51
-Request and Report State Mental
					 Institutions.
PA 52
-Application-Foster Child Care.
PA 52-C
-Notice of Change in Eligibility
					 for Foster Care Payment.
PA 52-F
-Child Welfare Service Agreement.
PA 52-R
-Annual Report-Foster Child Care.
PA 53
-PA Foster Home and Institutional
					 Care Payment Report.
PA 53-S
-Summary Invoice for Foster Home
					 and Institutional Care Payment Report.
PA 54
-Clearance of Mismatches-Enumeration
					 Process.
PA 57
-Institution Agreement.
PA 60-P
-Medical Report Pulmonary.
PA 61-S
-Social Information Supplement.
PA 62
-Social Information for Aid to the
					 Disabled Assistance.
PA 72
-Missing Relative Summary.
PA 73
-Request for Information.
PA 75
-Employer's File Card.
PA 76
-Request for Financial Information.
PA 78
-Request for Confidential Employment
					 Information.
PA 79
-Request for Legal Information.
PA 83-Z
-Request for Insurance Data.
PA 84
-Request for Information from
					 Unemployment Records.
PA 84-M
-Request for Information Bureau of
					 Motor Vehicles.
PA 84-R
-Authorization and Request for
					 Information Railroad Retirement Board.
PA 84-V
-Request for Verification of
					 Birth.
PA 84-W
-Request for Workmen's Compensation
					 Information.
PA 85
-Case Message.
PA 87
-Alphabetical Index Card.
PA 88
-Geographical Index File Card.
PA 89
-Cross Reference Card.
PA 90
-Application Control Card.
PA 90-M
-Medical Application Control
					 Card.
PA 91
-Master Index File Information Only
					 Card.
PA 93
-Sample Data Report on Medical
					 Assistance.
PA 94
-Case Record Request.
PA 95
-Caseworker Notice.
PA 95-N
-General Control Notice.
PA 96
-Quality Control Card.
PA 96-S
-Quality Control Card Supplement.
PA 117
-Monthly Report on Medical Exams and
					 Hearing to Determine Exempt Status.
PA 118
-Burial Request-Invoice.
PA 122
-Authorization for Assistance.
PA 122-E
-CBA Disbursement Authorization.
PA 122-N
-Authorization for Nursing Home
					 Care.
PA 122-PC
-Petty Cash Voucher.
PA 122-R
-Authorization to Vendor.
PA 122 Turnaround
-Authorization for
					 Assistance.
PA 123-E
-County Disbursement Notice of
					 Credit.
PA 124
-NMP Authorization Card.
PA 124-C
-NMP Closing Card.
PA 127
-Report of Applications Other than
					 MA (T).
PA 127-M
-Report of Applications Medical
					 Assistance.
PA 128
-Report of Employable Persons.
PA 153-A
-Temporary Recording Sheet.
PA 157
-Report of Exception-County Reply.
PA 162
-Notice to Applicant.
PA 162-A
-Advance Notice.
PA 162-C
-Confirming Notice.
PA 162-D
-Notice to Applicant for
					 Domiciliary Care.
PA 162-M
-Eligibility-Medical Assistance.
PA 162-S
-Discontinuance Authorization.
PA 163
-Request for Address and/or Amount
					 of Assistance.
PA 173-B
-Referral for Support Action.
PA 173-C
-Application for Unadjusted
					 Assistance Grant and Authorization to Pay Support Order Payments to the
					 Department of Human Services.
PA 173-D
-Stipulation to Change
					 Beneficiary.
PA 173-E
-Authorization to Change
					 Beneficiary and to Pay Order and Arrearages to DHS.
PA 173-F
-Notice of Support Referral.
PA 173-K
-Agreement and Authorization to
					 Pay Claim.
PA 173-M
-Medical Assistance Referral for
					 Court Action.
PA 173-S
-Reimbursement Referral.
PA 176-K
-Agreement and Authorization to
					 Pay Claim.
PA 176-KM
-Agreement and Authorization to
					 Pay Medical Assistance Claim.
PA 176-S
-Reimbursement Authorization.
PA 176-U
-Agreement to Pay Claim-Delayed UC
					 Checks.
PA 184-S
-Suggestion of Non-Payment.
PA 189
-Overpayment Referral.
PA 189-A
-Suspected Grant Referral
					 Disposition Notice.
PA 189-R
-Claim Settlement Report on
					 Referral.
PA 189-X
-Overpayment Investigation
					 Control.
PA 198
-Assignment Receipt.
PA 198-S
-Assignment of Interest in
					 Decedent's Estate.
PA 205
-Notice of Returned Check.
PA 205-S
-Notice of Suspension.
PA 207
-Request for: Investigation of Check
					 and/or Waiver of Investigation of Check.
PA 207-DP
-Authorization Correction
					 Notice.
PA 210
-Referral to County Administrator.
PA 212
-Notice of Appointment with County
					 Administrator.
PA 213
-Progress Report.
PA 214
-Monthly Report of Advancements,
					 Expenditures and Balances Emergency Fund.
PA 258-N
-Request for NHC Payment.
PA 259
-Standard Medical Invoice.
PA 259-C
-Request for Correction of Payment
					 Medical Assistance.
PA 250-NS
-Nursing Invoice.
PA 259-P
-Institutional Care Invoice
					 Certification.
PA 259-S
-Invoice Transmittal.
PA 260-F
-Recommendation by County Review
					 Team.
PA 293
-Child Support Action Notice.
PA 295
-School Medical Referral.
PA 296
-Social Security Number Consent
					 Statement.
PA 340
-Application for Assistance.
PA 364
-Retirement Check Transmittal.
PA 408
-Verification of Social Security
					 Number.
PA 409
-Enumeration-Clerical Control
					 Sheet.
PA 430
-Medical Eligibility
					 Authorization.
PA 451
-Report of Personal Interview.
PA 653
-Notice of Caseworker Change.
PA 740
-Face Sheet.
PA 742
-Income/Change Sheet.
PA 743
-Eligibility Form.
PA 743-C
-Eligibility Form.
PA 743-R
-Eligibility Form.
PA 743-RE
-Eligibility Form.
PA 743-S
-Rights and Responsibilities.
PA 745
-Domiciliary Care Redetermination
					 Report.
PA 746
-Termination State Supplement for
					 Domiciliary Care.
PA 747
-Authorization State Supplement for
					 Domiciliary Care.
PW 361
-Standard Transmittal.
PW 361-S
-Standard Transmittal
					 Supplement.
PW-SS 205
-SSA referral and disposition of
					 services.
SAU-2
-IMU Allowance Request.
SAU-3
-Monthly Referral/Registration
					 Activity.
SAU-4
-SAU Certification Record.
SRS117A
-WIN Certification Report.
SRS 117B
-AFDC WIN Grant Reductions
					 Report.
SS-5
-Application for a Social Security
					 Number.
SSA-5
-Application for Social Security
					 Number.
SSA 1610
-Request for Information from
					 SSA.
SSA 8036
-Notice of SSI Eligibility.
SSA 8220
-SSA State SSI Information
					 Exchange Form.
UC-46
-Status of Overpayment.