Pa Welfare Life Sustaining Medication Form – Fill Out and Use This PDF

P E N N S Y L V A N I A

Application for Medical Assistance for

Workers with Disabilities

Medical Assistance for Workers with Disabilities (MAWD) offers health care coverage for individuals with

disabilities who are employed. There may be a nominal fee for this coverage.

If you have a disability and need this form in large print or another format, please call our

helpline at 1-800-692-7462. TDD services are available at 1-800-451-5886.

This is an application for Medical Assistance benefits. If you need help translating it, please contact your county assistance office, CAO. Translation services will be provided free of charge.

Esta es una solicitud de beneficious de Asistencia Médica. Si necesita ayuda con la traducción comuníquese con

la Oficina de Asistencia del Condado (CAO) que le corresponde. Los servicios de traducción son gratuitos.

Client Rights and Responsibilities

Right to Non-discrimination

In accordance with Federal law and U.S. Department of Health and Human Services, or HHS, Policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, or disability. To file a complaint of discrimination, contact HHS. Write HHS, Director, Office of Civil Rights, Room 506-F, 200 Independence Avenue, S. W. Washington, D.C. 20201 or call

(202) 619-0403 (Voice) or (202) 619-3257 (TTD). HHS is an equal opportunity provider and employer.

Right to Confidentiality

We keep information you give confidential and use it only to administer the programs you apply for and/or may be eligible for.

Right to a Written Notice

We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on the notice. You have 30 days from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons given.

Right to Appeal

You have the right to ask for a departmental hearing to appeal a decision of or a failure to act by the department which affects your benefits or that you feel is unfair or incorrect. You may file the appeal at the CAO. At the appeal hearing, you may represent yourself, or someone else, such as a lawyer, friend or relative, may represent you. You may have an agency conference before the hearing.

Right to Certificate of Creditable Coverage

You have a right to a certificate of coverage to verify your medical coverage. Federal law limits when health care coverage may be denied or limited for a pre-existing condition. If you enroll in a health plan that allows for a pre-existing condition, exclusion or limitation, you may get credit for the time you received Medical Assistance.

Responsibility to provide Social Security Numbers

You must provide a Social Security number, or SSN for each person for whom you are applying. If you do not have a SSN, we will help you apply for one. Refusal or failure to provide an SSN may result in ineligiblity. We will also ask you to supply a SSN to verify identity and administer our programs. We will use your SSN to prevent duplication in state and federal programs and to get information about income to determine eligibility for benefits.

Responsibility to Provide Information

You must give true, correct and complete information. You must cooperate in documenting or proving the information you give. If you cannot provide proof, you should ask the CAO to help. You must cooperate fully with persons or investigators of Department of Public Welfare, DPW, or Office of Inspector General conducting investigations.

Responsibility to Report Changes

You must report changes in the number of people in your household, address, new unearned income, real property or other resources (such as bank accounts or life insurance). You must report any plans to leave the state, even temporarily. You must report if your gross monthly earned income increases by more than $100. If you have unearned income, you must report if your gross monthly unearned income increases by more than $50. You can report changes to the CAO in person, by telephone, by fax or by mail.

Changes must be reported within the first 10 days of the month following the month of the change.

Responsibility to use the PA ACCESS Card Lawfully

You may use the PA ACCESS card for the services only during the period you are eligible. You must use the card only for the person who is eligible and you may get only the services that are needed and reasonable.

Responsibility to Pay Monthly Premium

You are responsible for the payment of your monthly premium. If you do not pay your premium timely, you may lose your health coverage.

If You Cannot Pay Your Premium

Your monthly premium can be waived for reasons such as ongoing health problems, layoff or loss of employment, discrimination, or other factors beyond your control. You must also intend to return to the former position or be making a bona fide effort to seek other employment.

Responsibility to Contact Providers for Refunds

If you pay for any medical bills between the date of application and the determination of your eligibility, you are responsible for contacting the provider for a refund.

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COUNTY ASSISTANCE OFFICE USE ONLY

AUTHORIZED

UNAUTHORIZED

ｑ＃MAIL ｑ＃WALK IN

FILE CLEAR BY/DATE

SCREEN BY/DATE

DATE

COUNTY

DISTRICT

APPLICATION REG. NUMBER

DATE STAMP

BY

WORKER ID

CASE LOAD

RECORD NUMBER

CAT

CAT

NAME

APPOINTMENT DATE/TIME

ｑ＃

REASON CODE

AM

ｑ

＃

PM

TELL US ABOUT YOU, THE PERSON APPLYING

YOUR NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

ADDRESS

STATE

ZIP CODE

PLUS 4

TELEPHONE NUMBER

SCHOOL DISTRICT

TOWNSHIP (CIVIL SUBDIVISION)

Are you receiving Social Security Disability Insurance (SSDI) benefits?

ｑ＃Yes＃

ｑ＃No＃ ｑ＃Don’t Know

If no, tell us about your disability and provide documentation.

When filling out this application, please attach separate sheets if additional

space is needed.

Voter Registration (Optional)

If you or any other adult in your household is not registered to vote where you live now, would you like to register to vote? ___ Yes ___ No If yes, enter the names below. IF YOU DO NOT CHECK ‘YES’ OR ‘NO’, OR RETURN THE FORM, YOU ARE CHOOSING NOT TO REGISTER TO VOTE AT THIS TIME.

To register, you must: 1) Be at least 18 on the day of the next election; 2) Be a citizen of the United States for at least one month PRIOR TO THE NEXT ELECTION; 3) Reside in Pennsylvania and the voting district at least 30 days prior to the next election.

YOUR BENEFITS WILL NOT BE AFFECTED IF YOU REGISTER OR DO NOT REGISTER.

If you need help filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Please contact the Central Unit if you need help. If you believe that someone has interfered with your right to vote, or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-free telephone number 1-877-VOTESPA.)

DO NOT COMPLETE: COUNTY ASSISTANCE OFFICE USE ONLY

ｑ＃Given to Client __/__/__	ｑ＃Sent to voter registration __/__/__	ｑ＃Mailed to Client __/__/__
ｑ＃Declined, not interested __/__/__	ｑ＃Not a U.S. citizen __/__/__	ｑ＃Declined, already registered __/__/__

1	PA 600 WD (SG) 6/11

1. HOUSEHOLD, CITIZENSHIP, AND IDENTITY INFORMATION

Please list the people who live with you, starting with yourself. Make sure you look below for the application Race Code (the race code is optional and for statistical purposes only, and has no affect on your eligibility for benefits) and Citizenship Code. Attach additional sheets if needed.

Do you understand English? ＃Yes＃ ＃No If no, what language(s) do you understand?

____________________________________________________________________________________________

____________________________________________________________________________________________

CITIZENSHIP: Use one of the following codes:

1. US Citizen

2. Permanent Alien

3. Temporary Alien

4. Refugee

5. Undocumented Alien

6. Refugee Unaccompanied Minor

FOR RACE (Optional): Use any of the following codes that apply. Your benefits will not be affected if you do not answer. Individuals may fit more than one group.

1. Black 2. Hispanic

3. North American Indian or Alaskan Native 4. Asian 5. White (Not Hispanic) 6. Other

7. Native Hawaiian or Pacific Islander

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

ｑ＃Male

ｑ＃Female

NAME ON BIRTH CERTIFICATE (Last, First, M.I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

ｑ＃Yes

ｑ＃No

MOTHER’S MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Driver’s License (State & Number) or State ID No.

Relationship of Applicant to You

Access Card?

ｑ＃No

ｑ＃Yes

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

ｑ＃Male

ｑ＃Female

NAME ON BIRTH CERTIFICATE (Last, First, M.I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

ｑ＃Yes

ｑ＃No

MOTHER’S MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Driver’s License (State & Number) or State ID No.

Relationship of Applicant to You

Access Card?

ｑ＃Yes

ｑ＃No

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

ｑ＃Male

ｑ＃Female

NAME ON BIRTH CERTIFICATE (Last, First, M. I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

ｑ＃Yes

ｑ＃No

MOTHER’S MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Driver’s License (State & Number) or State ID No.

Relationship of Applicant to You

Access Card?

ｑ＃No

ｑ＃Yes

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

ｑ＃Male

ｑ＃Female

NAME ON BIRTH CERTIFICATE (Last, First, M. I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

ｑ＃Yes

ｑ＃No

MOTHER’S MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Driver’s License (State & Number) or State ID No.

Relationship of Applicant to You

Access Card?

ｑ＃No

ｑ＃Yes

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

ｑ＃Male

ｑ＃Female

NAME ON BIRTH CERTIFICATE (Last, First, M. I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

ｑ＃Yes

ｑ＃No

MOTHER’S MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Driver’s License (State & Number) or State ID No.

Relationship of Applicant to You

Access Card?

ｑ＃No

ｑ＃Yes

2

2. INCOME

Please tell us if anyone listed on this application has, or is expecting any type of income. List the income amount before deductions (such as taxes or insurance) are taken out. Income includes but is not limited to:

ﾆ Wages	ﾆ Baby Sitting	ﾆ Rent	ﾆ Veterans Benefits			ﾆ Sick Benefits	ﾆ Dividends or Interest
ﾆ Self-Employment ﾆ Room and Board		ﾆ Social Security/SSI	ﾆ Support or Alimony			ﾆ Unemployment or Worker’s Compensation
ﾆ Pensions	ﾆ Commissions	ﾆ Money for College or Training
	NAME	EMPLOYER OR			EMPLOYER’S ADDRESS		TELEPHONE
		SOURCE OF INCOME

HOURS WORKED	HOURLY	HOW OFTEN IS INCOME RECIEVED?	GROSS AMOUNT
PER WEEK	WAGE	(CIRCLE ONE)	BEFORE DEDUCTIONS

Weekly / Bi-weekly / Monthly / Other (explain)

Weekly / Bi-weekly / Monthly / Other (explain)

Weekly / Bi-weekly / Monthly / Other (explain)

Weekly / Bi-weekly / Monthly / Other (explain)

Weekly / Bi-weekly / Monthly / Other (explain)

3. EXPENSES

You may have spent money in order to receive income. If you did, please list the expense(s) below:

ﾆ Court Costs or Attorney Fees ﾆ Transportation ﾆ Impairment related work expenses

(such as medical devices, or attendant care)

3	PA 600 WD (SG) 6/11

4. RESOURCES

Does anyone listed on this application have any of the following resources?

ﾆYes ﾆ No Cash-on-hand (01)	ﾆYes ﾆ No Trust Fund (06)
ﾆYes ﾆ No Savings Account (02)	ﾆYes ﾆ No Certificate of Deposit (26)
ﾆYes ﾆ No Checking Account (03)	ﾆYes ﾆ No IRA, KEOGH, or other retirement plan (27)
ﾆYes ﾆ No Christmas or Vacation Club (04)	ﾆYes ﾆ No Burial Reserves or Trusts (97)
ﾆYes ﾆ No Stocks or Bonds (05)	ﾆYes ﾆ No Non-resident Property (98)
ﾆYes ﾆ No U.S. Savings Bonds (05)

ｑ＃Yes ｑ＃No Is anyone listed on this application expecting money or any type of resource such as, but not limited to, an accident settlement, inheritance, trust fund or other resource? If yes, type of resource: __________________ Value: ____________ Date expected: ___________________

ｑ＃Yes ｑ＃No Since February 8, 2006 have you or anyone listed on the application given away, sold or transferred any assets such as: a home, land, personal property, life insurance policies, annuities, bank accounts, certificates of deposit, stocks, IRA, bonds or a right to income? If yes, describe the type of property: __________________ Value: ____________ Date sold, transferred, or given away: ____________________

Does anyone listed on this application own or are they making payments on a vehicle (car, truck, motorcycle)? ｑ＃Yes							ｑ＃No
NAME	YEAR	MAKE		MODEL	LICENSED		AMOUNT OWED
					ｑ＃Yes ｑ＃No
					ｑ＃Yes ｑ＃No
Does anyone listed on this application have a life insurance policy?				ｑ＃Yes ｑ＃No

Does anyone listed on this application have health insurance besides Medical Assistance?

ｑ＃Yes ｑ＃No

5. BENEFITS FOR PREGNANT WOMEN

There are additional benefits which may be available to pregnant women. Complete this section if you want to make a referral for someone in your household who is pregnant.

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6. U.S. MILITARY SERVICE

Is anyone in the U.S. military, or has been in the U.S. military? ｑ＃Yes ｑ＃No

Is anyone a widow, spouse, or child (under age 18) of anyone in the U.S. military, or anyone who has been in
the U.S. military?	ｑ＃Yes	ｑ＃No

7. IF YOU HAVE UNPAID MEDICAL BILLS

If you have unpaid medical bills for up to three months before the application date, those bills could be covered.

This is called retroactive coverage. If you are determined eligible for retroactive coverage, you may be responsible for premium payments for each retroactive month. Please note that your retroactive bills will not be covered until these premium payments are received. If you think your bills might be less than the premium payment, you may not want to apply for retroactive coverage. Complete the section below if you wish to be considered for retroactive coverage. Please list any additional bills on a separate sheet of paper.

Please Note: You must submit verification of your income and resources for all months in which retroactive coverage is requested.

5	PA 600 WD (SG) 6/11

8. ATTACH PROOF

We will need proof of the information you have provided to process your application. If you are unable to obtain proof of the information, your CAO will help you.

ｑCheck here if you need help getting proof of your address, income and/or resources.

Do you have copies of the information you provided? ｑ＃Yes ｑ＃No

	PLEASE SEND COPIES - NOT ORIGINALS
Identification (only one source)		driver’s license, passport, photo ID
Citizenship		birth certificate or passport
Alien status (only if non-U.S. citizen)		Most current immigration documents
Address (only one source)		rent receipt, utility bill, driver’s license (with current address), mortgage bill or receipt,
		post office records, tax records, etc.
		One month’s current pay stub, proof of pension, Financial Eligibility Notice for Unemployment
Income		Compensation, tax forms or other records of self-employment income, copies of check stubs
		or statements from the source of income.
Resources		bank statements, insurance policies, Tax Assessment Notices

If you are unable to obtain proof of the information you have provided, the county assistance office will help you. Please attach a note explaining why you are unable to provide the proof.

9. WHEN WILL BENEFITS BEGIN?

You may choose the month you want Medical Assistance to start. Check (Ｙ)one of the boxes below:

10. HOW TO PAY THE PREMIUM

To participate in this program, you must pay a monthly premium. The preferred method of payment is payroll deduction. With payroll deduction, your employer will deduct the monthly premium amount directly from your paycheck. Please check the box below if you want payroll deduction.

YES, I want payroll deduction

If you are self-employed, do not want payroll deduction, or your employer doesn’t offer payroll deduction, you will be sent a monthly statement. You will be responsible for mailing that statement each month with your payment. Please check the box below if you want a monthly statement, and do not want payroll deduction

NO, I do not want payroll deduction.

NOTE: In some cases, you may not be required to pay a premium.

6

11. YOUR RIGHTS AND RESPONSIBILITIES

RIGHT TO NON-DISCRIMINATION

In accordance with Federal law and U.S. Department of Health and Human Services, or HHS, Policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, or disability. To file a complaint of discrimination, contact HHS. Write HHS, Director, Office of Civil Rights, Room 506-F, 200 Independence Avenue, S. W. Washington, D.C. 20201 or call (202) 619-0403 (Voice) or (202) 619-3257 (TTD). HHS is an equal opportunity provider and employer.

RIGHT TO CONFIDENTIALITY

We keep information you give confidential and use it only to administer the programs you apply for and/or may be eligible for.

RIGHT TO A WRITTEN NOTICE

We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on the notice. You have 30 days from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons given.

RIGHT TO APPEAL

You have the right to ask for a departmental hearing to appeal a decision of or a failure to act by the department which affects your benefits or that you feel is unfair or incorrect. You may file the appeal at the CAO. At the appeal hearing, you may represent yourself, or someone else, such as a lawyer, friend or relative, may represent you. You may have an agency conference before the hearing.

RIGHT TO CERTIFICATE OF CREDITABLE COVERAGE

You have a right to a certificate of coverage to verify your medical coverage. Federal law limits when health care coverage may be denied or limited for a pre-existing condition. If you enroll in a health plan that allows for a pre-existing condition, exclusion or limitation, you may get credit for the time you received Medical Assistance.

RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERS

You must provide a Social Security number, or SSN, for each person for whom you are applying. If you do not have an SSN, we will help you apply for one. Refusal or failure to provide an SSN may result in ineligiblity. We will also ask you to supply an SSN to verify identity and administer our programs. We will use your SSN to prevent duplication in state and federal programs and to get information about income to determine eligibility for benefits.

RESPONSIBILITY TO PROVIDE INFORMATION

You must give true, correct and complete information. You must cooperate in documenting or proving the information you give. If you cannot provide proof, you should ask the CAO to help. You must cooperate fully with persons or investigators of DPW or Office of Inspector General conducting investigations.

RESPONSIBILITY TO REPORT CHANGES

You must report changes in the number of people in your household, address, new unearned income, real property or other resources (such as bank accounts or life insurance). You must report any plans to leave the state, even temporarily. You must report if your gross monthly earned income increases by more than $100. If you have unearned income, you must report if your gross monthly unearned income increases by more than $50. You can report changes to the CAO in person, by telephone, by fax or by mail. Changes must be reported within the first

10 days of the month following the month of the change.

RESPONSIBILITY TO USE THE PA ACCESS CARD LAWFULLY

You may use the PA ACCESS card for services only during the period you are eligible. You must use the card only for the person who is eligible and you may get only the services that are needed and reasonable.

RESPONSIBILITY TO PAY MONTHLY PREMIUM

You are responsible for the payment of your monthly premium. If you do not pay your premium timely, you may lose your health coverage.

IF YOU CANNOT PAY MONTHLY PREMIUM

Your monthly premium can be waived for reasons such as ongoing health problems, layoff or loss of employment, discrimination, or other factors beyond your control. You must also intend to return to the former position or be making a bona fide effort to seek other employment.

RESPONSIBILITY TO CONTACT PROVIDERS FOR REFUNDS

If you pay for any medical bills between the date of application and the determination of your eligibility, you are responsible for contacting the provider for a refund.

7	PA 600 WD (SG) 6/11

12. AGREEMENT AND UNDERSTANDING

CLIENT OR REPRESENTATIVE SIGNATURE

Signature of Client/Representative					Signature of Witness (if “x” used above)
Address of Client/Representative					Address of Witness
Telephone			Date		Telephone			Date

8	PA 600 WD (SG) 6/11