Form PA 1663 at a glance
What it is: The Pennsylvania Department of Human Services Employability Assessment Form (PA 1663) documents a physical or mental disability which precludes gainful employment, for General Assistance, GA.
Where and when to file: General Assistance benefits cannot be authorized for you until the fully-completed form is returned to the county assistance office worker.
An individual with a physical or mental disability which temporarily or permanently precludes him or her from any gainful employment may be eligible for General Assistance, GA. This form must be completed to document the disability.
The assessment may be performed only by a licensed physician, physician's assistant, certified registered nurse practitioner, or psychologist.
A filled-in Form PA 1663 example: a physician completes Section II
How to fill out Form PA 1663, box by box
Section I
Section I must be completed by the applicant/recipient for public assistance. Review any information printed in Section I. If this information is incorrect, strike it out and write in the correct information. Print or write clearly. Be sure to sign your name and date this form in the appropriate space.
Briefly explain why you believe you cannot work.
I hereby authorize all medical providers to release any medical information that is related to my employability to the Pennsylvania Department of Human Services.
After you have completed this section, arrange for an appointment with a licensed physician (medical doctor or doctor of osteopathy), physician's assistant, certified registered nurse practitioner, or psychologist.
Employability
Section II is to be completed by a licensed physician, physician's assistant, certified registered nurse practitioner, or psychologist. Please complete this section based on your evaluation of the patient's statement in Section I, your examination of the patient, and your use of other medical procedures.
Employability: check only one.
Permanently Disabled: check this block if the client should be considered permanently disabled and, therefore, unable to work. Has a physical or mental disability which permanently precludes any gainful employment.
When making this determination, you must consider whether the client is unable to engage in any gainful employment by reason of any medically determinable physical or mental impairments.
The patient is a candidate for Social Security Disability or SSI.
There are two blocks for use in evaluating a client who is temporarily disabled: one for a client whose disability is expected to last 12 months or more, and one for a client whose disability is expected to last less than 12 months.
Check the appropriate block if the client has an injury or condition that temporarily prevents the client from working in any gainful employment.
Temporarily Disabled, 12 months or more, or less than 12 months: is currently disabled due to a temporary condition as a result of an injury or an acute condition and the disability temporarily precludes any gainful employment. The temporary disability began DATE and is expected to last until DATE.
Temporarily Disabled, 12 months or more: the patient may be a candidate for Social Security Disability or SSI benefits.
The date shown is when the temporary disability is expected to end.
Employable: check this block if, based on your examination, it is not appropriate to check either the Permanently or Temporarily Disabled blocks. The patient's physical and/or mental condition is such that he or she can work.
Examination results
Examination results: both parts of this section must be completed if #1, #2 or #3 is checked. If not completed, the client will be ineligible for GA.
This section must be fully completed so that it clearly establishes the basis for your decision that the client is either temporarily or permanently disabled. Simply providing a diagnosis is not sufficient. You must provide information about the basis for your diagnosis and assessment.
Diagnosis (Primary and Secondary): enter the Primary diagnosis and the Secondary diagnosis.
Assessment based upon (check all that apply): A. Physical examination, B. Review of medical records, C. Clinical history, D. Appropriate tests and diagnostic procedures, E. Other (Specify).
Documentation sufficient to support your decision, for example medical records, X-rays, and lab reports, must be available for further review if required.
Medical provider
As a licensed medical provider, I certify that I have read and complied with the attached instructions and the information is true and correct to the best of my professional knowledge.
Only the individual who performed the employability assessment may sign the form. The signature must be original or the form will be invalidated.
Enter the Medical Provider (print name), Telephone No. and Address, then add the Signature, Medical Assistance Provider No. and Date.
More rules for Form PA 1663
The information on the form and attachments must be complete and legible. If possible, the form and any attachments should be typed.
If all questions are not answered fully, the client's application will be delayed and the form returned to you for completion.
Questions: contact your local county assistance office.
Common questions about Form PA 1663
Where do I file it?
General Assistance benefits cannot be authorized for you until the fully-completed form is returned to the county assistance office worker.
Sources
[1] Employability Assessment Form (PA 1663 (SG) 8/18), Pennsylvania Department of Human Services (the Official source link on this page).