Pa 1671 Form PDF Details

In an effort to support individuals who require medication to maintain their employment, the Pennsylvania Department of Public Welfare has introduced the PA 1671 form, a crucial document designed to assess the need for health-sustaining medication among applicants and recipients of public assistance. Mandated to be filled out by licensed medical providers such as physicians, physician-assistants, certified registered nurse practitioners, or psychologists, this form serves a fundamental purpose in ensuring that those in need receive the appropriate support to continue their employment without hindrance from medical conditions. The form requests detailed information concerning the diagnosis requiring medication, the specific medications needed, and a clear explanation of the inability to work without these medications, underscored by a mandatory original signature from both the medical provider and the applicant. This ensures a comprehensive review process by the County Assistance Office (CAO), with the ultimate goal of determining eligibility for benefits, while emphasizing the importance of legibility and thoroughness in the documentation provided. Through the PA 1671 form, the Department of Public Welfare aims to facilitate a more accessible and efficient pathway for individuals requiring medication to sustain not just their health, but their livelihoods as well.

QuestionAnswer
Form NamePa 1671 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshealth sustaining medication examples, health sustaining medication form, health sustaining medication forms for dpw, pennsylvania department of public welfare health sustaining medication assessment form

Form Preview Example

CAO NAME ANDADDRESS

 

 

 

 

 

 

 

CASEIDENTIFICATION

 

 

 

 

 

 

 

 

 

 

CO

RECORD NUMBER

CAT

CSLD

DIST

 

 

 

 

 

 

 

 

 

RECORD NAME

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PENNSYLVANIADEPARTMENT OF PUBLIC WELFARE

HEALTH-SUSTAINING MEDICATION ASSESSMENT FORM

APPLICANT/RECIPIENTNAME:

WORKER:

This form is to be completed for the applicant/recipient who requires medication that allows the person to be employable or continue with employment. All items in this section must be completed by a licensed prescriber and signed by both the physician and applicant/recipient.

Does the applicant/recipient need health-sustaining medication? Yes No

If no, you do not need to enter any further information. Just sign and date. If Yes, complete the following information.

Diagnosis:

Medication(s) needed for the APPLICANT/RECIPIENTto sustain employment based on the above diagnosis:

Explain why the APPLICANT/RECIPIENTcannot work in any capacity without this medication. (Please be specific)

MEDICALPROVIDER:

ADDRESS:

TELEPHONE NUMBER:

SIGNATURE

DATE

I HEREBYAUTHORIZE ALLMEDICALPROVIDERS, INDIVIDUALOR FACILITYOF WHATEVER TYPE, INCLUDING MENTAL HEALTH AND DRUG OR ALCOHOLTREATMENTTO RELEASE ALLMEDICAL/CLINICALINFORMATION TO THE PENNSYLVANIA DEPARTMENTOF PUBLIC WELFARE (DPW) WHICH RELATES TO MYABILITYTO WORK.

X

(SIGNATURE)

PRINTED NAME

DATE

PUBLIC ASSISTANCE APPLICANT/RECIPIENT

See Reverse Side For Instructions

PA1671 (SG) 04/05

COMPLETION INSTRUCTIONS

HEALTH–SUSTAINING MEDICATION ASSESSMENT FORM

READ INSTRUCTIONS CONTAINING SPECIFIC DEFINITIONS AND REQUIREMENTS BEFORE

COMPLETING THE FORM

Medical information is required by the Department of Public Welfare (DPW) in determining whether an applicant qualifies for a certain category of public assistance benefits as well as his or her employability. Your medical assessment and documentation are necessary to help the CAO make these decisions.

Who may complete

The assessment may only be completed by the following licensed medical providers:

the assessment:

physician, physician-assistant, certified registered nurse practitioner, or psychologist.

Who signs the form:

Only the individual who completed the employability assessment may complete and sign

 

the form. Signature or clinic stamps, labels, and other facsimiles are not acceptable.

 

The signature must be original or the form will be invalidated.

General form

The information on the form and attachments must be legible. The inability of county

completion

staff to read your material will result in the client’s application being delayed and the form

requirements:

being returned to you for clarification. If at all 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.

Diagnosis:

Record your diagnosis of the applicant/recipient’s condition. The explanation should

 

indicate whether or not the condition is chronic or temporary. Attach documentation

 

sufficient to support your decision such as medical records, X-rays, and lab reports that

 

support your conclusion must be attached. Simply providing a diagnosis is not sufficient.

 

Without this documentation, the client will be determined ineligible for benefits.

Medication Needed:

List the medication(s) needed by the applicant/recipient that address his medical

 

condition thus enabling him/her to be able to work.

Explanation:

Explain in detail what the consequences to the applicant/recipient would be if the

 

medication(s) listed above were not available to him/her. Document in this section

 

whether the medication is for a chronic condition such as diabetes that the person will

 

be required to take for life. Also indicate if the medication will be needed for a limited

 

time period. If that is the case, show the date the person is expected to no longer need

 

the medication.

Questions:

Contact your local County Assistance Office at:

How to Edit Pa 1671 Form Online for Free

The PDF editor makes it easy to complete the pa medical assistant for adults life sustaining medication document. You should be able to prepare the file right away by using these basic steps.

Step 1: You can hit the orange "Get Form Now" button at the top of the web page.

Step 2: When you have entered your pa medical assistant for adults life sustaining medication edit page, you'll see all options you can undertake regarding your document within the top menu.

Complete the pa medical assistant for adults life sustaining medication PDF and type in the details for each and every section:

pa medical assistance form for medication health sustaining medication empty fields to fill out

Enter the appropriate details in Medications needed for the, Explain why the APPLICANTRECIPIENT, MEDICAL PROVIDER, ADDRESS, TELEPHONE NUMBER, SIGNATURE, DATE, I HEREBY AUTHORIZE ALL MEDICAL, SIGNATURE PUBLIC ASSISTANCE, See Reverse Side For Instructions, PRINTED NAME, and DATE section.

Finishing pa medical assistance form for medication health sustaining medication part 2

Step 3: When you have selected the Done button, your file should be ready for transfer to every gadget or email address you specify.

Step 4: Come up with a duplicate of each single document. It will save you some time and help you avoid concerns in the future. Also, your details isn't distributed or analyzed by us.

Watch Pa 1671 Form Video Instruction

Pa 1671 Form isn’t the one you’re looking for?

Related Documents

  • Pa Dl 3731 Form

    "... Driver license number last name, jr. Please read the important information on reverse side. Date of birth phone number 0030 mail address (if applicable) first name middle name messenger. No application options must be checked. ..."

  • Pa 100 Form

    "... Patient label op007 sr10 08 intensive outpatient program admission sheet. Name of the patient: patient name last name middle Are you known as any other name? No yes, mother maiden name. Address zip home telephone ..."

  • Pa 501

    "... Instructions for the preparation of form pa501 employer deposit statement for income tax withheld. Enter the quarter end date of the employer account ID if none are assigned federal entity id federal in. If none ..."

  • Pa Aa 600

    "... 6001109 commonwealth of pennsylvania drivers accident report forward this report within days to the pennsylvania department of transportation bureau of highway safety and traffic engineering po box 2047 harrisburg pa 171052047 pennsylvania vehicle code section 3747 states all reports are confidential not available as trial evidence date of accident month day year county day of week hour am pm check if hit run emi severity was towing required number of vehicles involved number injured number killed tun it yes noun it yes non to properly locate accidents use as city borough township on street name or highway number ot landmarks sr segment number sac mileposts intersection of two highways at intersection with if not at intersection feet nse woof station marker intersection etc city borough township or county lines operators name first middle last dateofbirth operators license number and state mr mrs om issn address street city state zip code vehicle license number and state el hi owners name first middle last year make model em rv mrs miss address street city state zip code pa title or out of state in use the following section to record vehicle number pedestrian or other property operators name first middle last dateofbirth operators license number and state mr mrs miss address street city state zip code vehicle license number and state re owners name first middle last year make model mr to mrs miss address street city state zip code pa title or out of state in description of damaged property check ..."

Please rate Pa 1671 Form

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .