Health Sustaining Medication Forms For Dpw Details

Pa 1671 form is a document that is used to report the sale or transfer of firearms. It is important that you understand how to complete this form correctly so that there is no confusion with the transaction. This guide will provide an overview of what information is required on the Pa 1671 form and how to submit it. If you have any questions, be sure to consult with a legal professional.

In the listing, there is some good information relating to the pa 1671 form. It's a good idea that you read through this information before you decide to begin fiddling with the PDF.

QuestionAnswer
Form NamePa 1671 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedical assistance life sustaining medication, life sustaining medication form pa, health sustaining medication forms for dpw, pa medical assistant for adults life sustaining medication

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: