Pa Ch 600 Form – Fill Out and Use This PDF

The Pa Ch 600 Form is a vital tool utilized by the Pennsylvania judiciary system. It was developed in an effort to manage civil procedure cases submitted to county rule. This form aids courtpersons in providing effective pathways in how their respective courtrooms handle said civil complaints and help streamline the process for easier navigation. With its well defined conditions, paperwork overload can be avoided with completing it as instructed. Created to ensure uniformity among regional courts, accuracy and speed are core reasons behind its implementation. All put together, the Pa Ch 600 is championing standardization and modernizing processes for court personnel and citizens alike.

Pa Ch 600 Form PDF Details

Are you a Pennsylvania business owner planning to apply for the PA-100 form? Understanding the underlying process can be challenging, but one of the most important steps is accurately completing and submitting the PA Ch 600 Form. This article provides an overview of what this form entails, including instructions on how to approach filling it out correctly so that you can successfully register your business in Pennsylvania.

Question	Answer
Form Name	Pa Ch 600 Form
Form Length	12 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min
Other names	pa 600 hc, pa600hc, pa form application coverage, pa600ch form

Form Preview Example

Important information about health care benefits.

Ask someone to read this to you.

APPLICATION FOR

Health Care Coverage

This application may be used by families with children or by pregnant women

who apply for health care benefits under the Medicaid program or the

Children’s Health Insurance Program (CHIP).

You can apply online at www.compass.state.pa.us

Health Care in Pennsylvania

Easy, affordable protection for your family

PA 600 CH.1 (SG) 12/06

Information about Health Care Coverage

Please note: If you need Medicaid benefits for families without children, cash assistance, or food stamps, you must complete a different application. Please call your County Assistance Office and they will send you the proper form.

If you need help: You can get help with this form. For help, you can call the Helpline at

1-800-842-2020 or ask for help at the County Assistance Office. If you are hearing impaired, call TDD 1-800-451-5886.

Health Care Coverage May Include:

•	Checkups	•	Immunizations
• Sickvisitsandprescriptiondrugs		• Visiontestingandeyeglasses
•	Emergencyroomcare	• LabtestsandX-rays
• Hearingtestingandhearingaids		•	Mentalhealthandsubstanceabusetreatment

Questions You Might Have

Q: Which program can my children enroll in?

A:WhetheryourchildrenenrollinMedicaidorCHIPdependsmostlyonyourincomeandtheages ofyourchildren.Youmayapplytotheprogramofyourchoice.Thisapplicationwillworkforboth programs.

•IfyouapplyfirsttoMedicaid,butarenoteligible,theapplicationwillbesenttoaCHIPprogram toseeifyouareeligible.

•IfyouapplyfirsttoCHIP,butarenoteligible,theapplicationwillbesenttotheCounty AssistanceOfficetoseeifyouareeligibleforMedicaid.

•Ifthishappens,youwillgetalettertellingyouwhathashappenedtotheapplicationandwhatto expect.

Q: How will I know if my family is eligible?

A:Youshouldreceivealetterfromtheprogramyouappliedtowithin30days.Thisletterwilltellyouwho iseligiblefortheprogramandwhoisnot.Ifsomeonedoesnotgetintotheprogram,theletterwilltell youwhyandwhatyoucandonext.

Q: What if someone in my family has a disability or a special health care need?

A:Youcannotbeturneddownforcoveragebecauseyouhaveadisabilityoraspecialneed.Ifyouor yourchildhasadisabilityoraspecialhealthcareneed,ahigherincomelimitcanbeusedwhenyou applyforMedicaid.Youmayalsobeabletoreceiveadditionalservices.

PA 600 CH.1 (SG) 12/06

▲ A f t e r c o m p l e t i o n - R e m o v e p a g e s 3 t h r o u g h 1 0 a t p e r f o r a t i o n a n d m a i l i n s u p p l i e d e n v e l o p e - K e e p f r o n t a n d b a c k c o v e r . ▲

Application for Health Care Coverage

Si necisita este información en español, llame al teléfone: 1-800-842-2020

What language do you prefer?	___ Spanish	___English	___Other (specify)____________________________
¿Qué idioma prefiere usted?	___ Español	___Inglés	___Other (especifique) ________________________

This form is for two programs: Medicaid (also known as Medical Assistance) and CHIP (Children’s Health Insurance Program).

All information you provide on this form will be shared between the two programs if necessary. It is confidential.

Medicaid: Provides health care coverage for children under age 21, pregnant women, and other adults.

CHIP: Provides health care coverage for children under age 19 who do not have health insurance and who are not eligible for Medicaid.

Whether your children are enrolled in CHIP or Medicaid will depend mostly on your income and the ages of your children.

1.Fill out the form. Please print.

2.Attach proof of all income your household received during the last 30 days.

•Proof includes pay stubs, award letters or checks.

•Make sure the pay stubs show a full month’s income and the pay period. (If paid every week, attach four pay stubs. If paid every two weeks attach two pay stubs.) Also, an employer can write a letter that states what the monthly pay is if there are no pay stubs.

•If self employed, copies of tax returns or receipts, or other records count as proof of income.

•The information you attach should show what the income is before taxes and deductions.

3.If you are applying for someone who is not a U.S. Citizen, please attach proof of alien status. (You do not need to attach proof of alien status if this is an emergency application for Medicaid.)

4.Mail or take this form to your local County Assistance Office. Call 1-800-842-2020 if you do not know where to send your form.

5.If you need help with this application, please call 1-800-842-2020, or if you are hearing impaired call TDD 1-800-451-5886.

I.Tell us who you are and where you live.

Last name (Parent/Caretaker)			First Name			Middle Initial

Social Security Number *	Street Address

City			County	State		Zip

Home Phone		Work Phone			Best time to call

*If you are not applying for yourself, you can leave this blank.

3	PA 600 CH.1 (SG) 12/06

II. Please list the people who live with you. Start with yourself.

Are you

Is this person

applying for

a student

How is this

a U.S.

this person?

Sex

Is this

Birthdate

under age 19?

person related

Citizen? *

Last name, first name, MI

Yes/No?

M or F

person:

MM/DD/YY

Social Security Number*

Yes/No?

to you?

Yes/No?

Married

Yourself

■

Single

■

Divorced

Self

■

Separated

■

Widowed

■

Married

Person 2

■

Child

■

Single

■

Stepchild

■

Divorced

■

Spouse

■

Separated

■

Other

■

Widowed

■

___________

Married

Person 3

■

Child

■

Single

■

Stepchild

■

Divorced

■

Spouse

■

Separated

■

Other

■

Widowed

■

___________

Person 4

Married

■

Child

■

Single

■

Stepchild

■

Divorced

■

Spouse

■

Separated

■

Other

■

Widowed

■

___________

Person 5

Married

■

Child

■

Single

■

Stepchild

■

Divorced

■

Spouse

■

Separated

■

Other

■

Widowed

■

___________

Person 6

Married

■

Child

■

Single

■

Stepchild

■

Divorced

■

Spouse

■

Separated

■

Other

■

Widowed

■

___________

Person 7

Married

■

Child

■

Single

■

Stepchild

■

Divorced

■

Spouse

■

Separated

■

Other

■

Widowed

■

___________

Person 8

Married

■

Child

■

Single

■

Stepchild

■

Divorced

■

Spouse

■

Separated

■

Other

■

Widowed

■

___________

*If you are not applying for this person, you can leave the Social Security Number space and the U.S. citizen space blank.

Are you, or is anyone who lives with you a stepparent?	■■ yes	■■ no	(if the answer is no, skip to section III)
Do the stepchildren live with you?	■■ yes	■■ no	If yes, tell us:

Stepparent’s name: ________________________________________________________________________________

Stepparent for which children? ________________________________________________________________________

Stepparent’s name: ________________________________________________________________________________

Stepparent for which children? ________________________________________________________________________

PA 600 CH.1 (SG) 12/06

III. Income and Expenses.

Please tell us about the income of any child or adult you have listed on this application.

How often is the income

Does anyone have income from:

received?(weekly,

Amount of monthly income before taxes and

(Please check YES or NO)

YES

Whose income is this?

bi-weekly, monthly, etc.)

deductions

Employment

YES

Employer’s Name:

Employment

YES

Employer’s Name:

Social Security Income

YES

Supplemental Security income (SSI)

YES

Pension/Retirement

YES

Worker’s Compensation

YES

Unemployment Benefits

YES

Dividends/Interest

YES

Self Employment (Including babysitting and

YES

room and board paid to you.)

Child Support/Alimony

YES

Public Assistance

YES

Other (Specify)

YES

Other (Specify)

YES

Some of your expenses can help make you eligible. Please tell us what

you pay for child care and adult care, and what you pay for

transportation to go to work.

Child Care & Adult Care Expenses Transportation Expenses

Name of child or disabled adult

Monthly expense amount

How much does it cost you to get to work each week if you ride with another person or take a bus, subway, or trolley?

If you drive to work, how many miles do you drive each week?

If you have a car, how much is your monthly payment?

5	PA 600 CH.1 (SG) 12/06

IV. Health Insurance

Medicaid can sometimes pay bills that your other health insurance doesn’t cover. If you or someone you are applying for has health insurance, please complete this section.

Does anyone you are applying for have health insurance?

■■ yes ■■ no

If yes, please fill in the next section and tell us all you can about the insurance. If no, skip this section.

If you have more than one kind of insurance, please fill in a box for each policy.

If more than one person has insurance, please fill in a box for each person.

Insurance Company

Who holds this policy?

Who is covered?

What is covered?

Hospital care

Prescriptions

Visions

■

Doctor’s visits

Dental

■

Policy number

Group number/name

When did this insurance start?

When did this insurance stop? (Leave blank if you are still covered)

Insurance Company

Who holds this policy?

Who is covered?

What is covered?

Hospital care

Prescriptions

Visions

■

Doctor’s visits

Dental

■

Policy number

Group number/name

When did this insurance start?

When did this insurance stop? (Leave blank if you are still covered)

Insurance Company

Who holds this policy?

Who is covered?

What is covered?

Prescriptions

Visions

■

Hospital care

■

Doctor’s visits

Dental

■

Policy number

Group number/name

When did this insurance start?

When did this insurance stop? (Leave blank if you are still covered)

Car Insurance

Car insurance will often pay for injuries that occur in an accident.

Medicaid will pay for only what the car insurance doesn’t cover.

Do you have car insurance? ■■ yes ■■ no

If yes, please fill in the next section. If no, you can leave it blank.

Insurance company name

Who holds this policy?

Policy number

Policy expiration date

PA 600 CH.1 (SG) 12/06

Health Insurance from Your Employer

Medicaid can sometimes buy health insurance for you or your children from your employer.

Please help us decide if this is possible by completing this section.

Please check yes or no	YES	NO
Can you get health insurance for yourself through your work?	YES	NO

If yes, would you have to pay for it?	YES	NO
	YES	NO

Can you get health insurance for your children through your work?	YES	NO
If yes, would you have to pay for it?	YES	NO

In the last 30 days, did anyone in your family lose a job where they had health insurance?	YES	NO

V. Special Qualifying Information

If someone you are applying for has a disability or a special health care need, a higher income limit can be used when your family applies for Medicaid. Additional services are available.

Please help us find out if anyone you are applying for is eligible for these programs.

					no If yes, tell us who?
Are you, or is anyone who lives with you, pregnant?	■■	yes		■■	no If yes, tell us who?
Name: ______________________________________________________________________								Due date: __________________________
Name: ______________________________________________________________________								Due date: __________________________


							yes			no
Do you, or does anyone who lives with you have a disability or a special health care need?						■■	yes		■■	no
If yes, tell us who, and about their needs?
Name: __________________________________________			What is the disability or condition (optional): ____________________________
Name: __________________________________________			What is the disability or condition (optional): ____________________________
Name: __________________________________________			What is the disability or condition (optional): ____________________________

Did anyone receive Supplemental Security income (SSI) in the past? ■■ yes ■■ no (If NO, you can skip this section) If yes, who? ________________________________________________________________________________________

Name: ________________________________	What is the disability or condition (optional): ________________________
Name: ________________________________	What is the disability or condition (optional): ________________________
Name: ________________________________	What is the disability or condition (optional): ________________________

Help with Unpaid Medical Bills

You may be able to get help from Medicaid for unpaid medical bills from the last 3 months.

Do you have any unpaid medical bills for anyone you are applying for? ■■ yes ■■ no

If yes, please give us copies of the bills and proof of income for those months.

•Proof includes pay stubs, award letters or checks.

•Make sure the pay stubs show a full month’s income and the pay period. (If paid every week, attach four pay stubs. If paid every two weeks attach two pay stubs.)

•If self employed, copies of tax returns or receipts, or other records count as proof of income.

•The information you attach should show what the income is before taxes and deductions.

7	PA 600 CH.1 (SG) 12/06

VI. Optional Information

None of these answers will affect your application for health care coverage.

Help with Child Support and Health Insurance

If you are eligible for Medicaid, you may be able to get help with child support payments and with health insurance for your child if he or she has a parent who does not live with you. Please complete the section below. Your children can still receive health care coverage if you do not complete this section.

Name of absent parent:	________________________________________________________________						check if deceased
Name of absent parent:					■		check if deceased

Absent Parent’s Street Address			City				State	Zip

Date of Birth:		Social Security Number	Which child(ren) is/was this parent responsible for?


Name of absent parent:	________________________________________________________________						check if deceased
Name of absent parent:					■		check if deceased

Absent Parent’s Street Address			City				State	Zip

Date of Birth:		Social Security Number	Which child(ren) is/was this parent responsible for?


Name of absent parent:	________________________________________________________________					check if deceased
Name of absent parent:				■		check if deceased

Absent Parent’s Street Address			City				State	Zip

Date of Birth:		Social Security Number	Which child(ren) is/was this parent responsible for?


Name of absent parent:	________________________________________________________________					check if deceased
Name of absent parent:				■		check if deceased

Absent Parent’s Street Address			City				State	Zip

Date of Birth:		Social Security Number	Which child(ren) is/was this parent responsible for?

PA 600 CH.1 (SG) 12/06

Optional Information (continued)

Please help us help other families by answering these questions.

How did you learn about CHIP and Medicaid? (You can check more than one box)

■ at the County Assistance Office	■ through a local community organization	■ through my children’s school
■ through CHIP	■ at my doctors office	■ through a family member
■ the 1-800-986-KIDS Helpline	■ at the hospital	■ through a friend or neighbor
■ on TV	■ through my work	■ other___________________________

■ on the radio

Did your children have health insurance in the past six months? ■■ yes ■■ no

If yes, please tell us if they lost their health insurance because:

■my job stopped providing health insurance for my children

■my job raised the cost of health insurance for my children

■the health insurance was too expensive

■my children no longer got health insurance through a child support order

■I no longer have a job

■other reason: __________________________________________________________________________________________________

What school district do you live in? ____________________________________________________________________________________

Racial and Ethnic Information

Racial and ethnic information about the people who live with you. Start with yourself.

Name

Race (check all that apply)

Ethnicity

Yourself

Hispanic

■

African American

■

Native Alaskan/American Indian

■

Asian

Native Hawaiian/Pacific Islander

Non Hispanic

■

Caucasian

Asian (Indian subcontinent)

■

Person 2

African American

Native Alaskan/American Indian

Hispanic

■

Asian

Native Hawaiian/Pacific Islander

Non Hispanic

■

Caucasian

Asian (Indian subcontinent)

■

Person 3

Hispanic

■

African American

Native Alaskan/American Indian

■

Asian

Native Hawaiian/Pacific Islander

Non Hispanic

■

Caucasian

Asian (Indian subcontinent)

■

Person 4

Hispanic

■

African American

■

Native Alaskan/American Indian

■

Asian

Native Hawaiian/Pacific Islander

Non Hispanic

■

Caucasian

Asian (Indian subcontinent)

■

Person 5

African American

Native Alaskan/American Indian

Hispanic

■

Asian

Native Hawaiian/Pacific Islander

Non Hispanic

■

Caucasian

Asian (Indian subcontinent)

■

Person 6

African American

Native Alaskan/American Indian

Hispanic

■

Asian

Native Hawaiian/Pacific Islander

Non Hispanic

■

Caucasian

Asian (Indian subcontinent)

■

Person 7

African American

Native Alaskan/American Indian

Hispanic

■

Asian

Native Hawaiian/Pacific Islander

Non Hispanic

■

Caucasian

Asian (Indian subcontinent)

■

Person 8

Native Alaskan/American Indian

Hispanic

■

African American

■

Native Hawaiian/Pacific Islander

Non Hispanic

■

Asian

■

Caucasian

Asian (Indian subcontinent)

■

9	PA 600 CH.1 (SG) 12/06

VII. You have certain rights and responsibilities. They are:

MEDICAID:

I understand that the information on this form will be kept confidential.

I authorize the release of personal, financial, and medical information for the purpose of determining eligibility and for review of the CHIP and Medicaid programs.

I understand that I must report all changes in my household or financial situation to the County Assistance Office within one week.

I understand that I can request a hearing if I do not agree with a decision made on this application.

I understand that my situation is subject to verification from employers, financial sources and other third parties.

I understand that Medicaid applicants must provide their Social Security Number. This number may be used to check the information on this application.

I understand that I have a right to a certificate of creditable coverage to verify my medical coverage. Federal law limits when health coverage may be denied or limited for a pre-existing condition. If I enroll in a group health plan that has a pre-existing condition, I can get credit for the time I received Medicaid.

I certify that all information on this application is true under penalty of perjury.

I certify to the best of my knowledge that I understand my rights and responsibilities.

CHIP:

I have read and fully understand this application. The information that I have given is true and correct.

I understand that there may be penalties for knowingly giving false information.

I understand that if some or all of my children do not qualify for CHIP, they may qualify for Medicaid. If this is the case, I will allow CHIP to give my name and the information on this application to the Department of Public Welfare.

I agree to help in the review of the CHIP program. I understand this may include interviews, and a review of my child’s health records and application form.

Signature of Applicant

or person applying for applicant(s): ______________________________________________________ Date: ______________________

Certification of Citizenship or Alien Status

By signing my name below, I certify that the persons that I am applying for are U.S. citizens or aliens in lawful immigration status. I know I must sign this in order to be eligible for Medicaid under law. (An alien who is applying only for Medicaid emergency health benefits does not have to sign this certification.)

Sign Here:____________________________________________________________________________

For Office Use Only

Source of Application: ■■ Helpline ■■ CAO ■■ CHIP Contractor (specify)__________________ ■■ Other (specify)_____________________

Date Received:	/	/	Categories: ______________________________________________
	__________________________
File Cleared By/Date:	/	/	/	/
	__________________________		Screened By/Date: ________________________________________
AP Registration#:	__________________________		Provider #: ______________________________________________

County: __________________________________ District: ____________________________ Record #: __________________________

■■ Authorized

■■ Not Authorized

■■ Reason Code ______________________________________________________________

PA 600 CH.1 (SG) 12/06

✃.records yourfor keepand linedotted alongCut

Information about

Health Care Coverage

Health Care Coverage May Include:

•Checkups

•Immunizations

•Sickvisitsandprescriptiondrugs

•Visiontestingandeyeglasses

•Emergencyroomcare

•LabtestsandX-rays

•Hearingtestingandhearingaids

•Mentalhealthandsubstanceabusetreatment

Questions You Might Have

Q:Which program can my children enroll in?

A:WhetheryourchildrenenrollinMedicaidorCHIP dependsmostlyonyourincomeandtheagesofyour children.Youmayapplytotheprogramofyourchoice. Thisapplicationwillworkforbothprograms.

•IfyouapplyfirsttoMedicaid,butarenoteligible, theapplicationwillbesenttoaCHIPprogramto seeifyouareeligible.

•IfyouapplyfirsttoCHIP,butarenoteligible,the applicationwillbesenttotheCountyAssistance OfficetoseeifyouareeligibleforMedicaid.

•Ifthishappens,youwillgetalettertellingyouwhat hashappenedtotheapplicationandwhatto expect.

Q:How will I know if my family is eligible?

A:Youshouldreceivealetterfromtheprogramyouapplied towithin30days.Thisletterwilltellyouwhoiseligible fortheprogramandwhoisnot.Ifsomeonedoesnotget intotheprogram,theletterwilltellyouwhyandwhatyou candonext.

Q:What if someone in my family has a disability or a special health care need?

A:Youcannotbeturneddownforcoveragebecauseyou haveadisabilityoraspecialneed.Ifyouoryourchild hasadisabilityoraspecialhealthcareneed,ahigher incomelimitcanbeusedwhenyouapplyforMedicaid. Youmayalsobeabletoreceiveadditionalservices.

PA 600 CH.1 (SG) 12/06

VII. You have certain rights and

responsibilities. They are: