Does the applicant/recipient need health-sustaining medication? If no, you do not need to enter any further information. Just sign and date.
Signature: the signature must be original or the form will be invalidated.
Documentation: attach documentation sufficient to support your decision such as medical records, X-rays, and lab reports that support your conclusion.
Questions: if all questions are not answered fully, the client's application will be delayed and the form returned to you for completion.
| Question | Answer |
|---|---|
| Form Name | PA 1671 Health Sustaining Medication Assessment Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 6 min |
| Where to send | Mail the application to your county assistance office (CAO) |
| Edition | 10/16 |
| Issuing agency | Pennsylvania Department of Human Services |
| Matches the agency's file | Yes, checked October 8, 2026 |
| Other names | PA 1671, PA 1671 (SG), Health Sustaining Medication Form, Health-Sustaining Medication Assessment Form |
| Official source | PA 1671 Health Sustaining Medication Assessment Form (Rev 10/16), Pennsylvania Department of Human Services |
Pa Welfare Life Sustaining Medication Form isn’t the one you’re looking for?