55 Pa. Code § 101.5. Forms.

§ 101.5. Forms.

(a)  Forms used in the administration of the public assistance program, including those which may be revised or renumbered are available from the Department of Human Services, Management Services, Post Office Box 2675, Harrisburg, Pennsylvania 17105.
(b)  The following is a list of several forms referred to on this part and their corresponding official designations:
   A-3—Treasury Investigation Form.
   A-4—Treasury Investigation Report Form.
   AG-1—Notice of Exception.
   AG-1 Part I—Identification Factors.
   AG-1 Part II—Eligibility Factors.
   AG-1 Part III—Explanation of Exception.
   CY 931—Certificate of Subsidized Adoption.
   DP 207—Request for Treasury Investigation.
   DHS 6190—Authorization to Sign Document.
   ES 1—Referral and Placement Report.
   ES 350—Applicants’ Record Card.
   IM-2—IM Referral to Vocational Rehabilitation.
   IM-3—Referral for WIN Registration.
   IM-6—AFDC WIN Change Notice.
   IM-9—AFDC WIN Grant Reduction Record.
   MA S-95—WIN Registration Record.
   MA 5-96—WIN Certification Record.
   MA 5-97—WIN Status Change Notice.
   MA 57—Hospital Admission Certification.
   MA 62—Social Information for Permanent and Total Disability.
   MA 215—Letter-Disability Review.
   OA-132—Accounting for Appropriation Advancement Voucher Transmittal.
   OA 275—Authorization of Signature Card.
   PA 1—Application for Assistance.
   PA 1-M—Application-Medical Assistance.
   PA 1-MS—Supplemental Application for Medical Assistance.
   PA 1-S—Supplemental Application for Medical Assistance.
   PA 1-SP—Application for Participation in Food Stamp Program.
   PA 3-R—Property Lien Notice.
   PA 4—Authorization for Information on Resources.
   PA 4-M—Medical Assistance Physician’s Prescription.
   PA 5A—Medical Identification Card (White).
   PA 5-A—Medical Identification Card (Blue).
   PA 5-B—Medical Identification Card (Pink).
   PA 5-C—Medical Identification Card (Green).
   PA 5-M—Certification-Medical Care.
   PA 6-F—Assignment of Insurance.
   PA 6-G—Distribution of Insurance Benefits.
   PA 6-K—Assurance as to Nonchange of Beneficiary.
   PA 6-M—Hospital Admission Certification.
   PA 9—Reimbursement Agreement.
   PA 13—Reference Card and Registration Report.
   PA 21—Face Sheet.
   PA 21-B—Blind Pension Authorization Sheet.
   PA 21-BI—Computation Sheet.
   PA 21-BN—Federal-State Blind Pension Authorization Sheet.
   PA 21-F—Legally Responsible Relatives.
   PA 21-H—Insurance—Burial Resources.
   PA 21-I—BP Property.
   PA 21-M—Computation of Resources Medical Assistance.
   PA 21-MR—Benefit Period Record.
   PA 21-MU—Medical Assistance Verification Summary.
   PA 21-N—NHC Authorization Sheet.
   PA 21-P—Authorization Sheet.
   PA 21-PF—Foster Care Authorization Sheet.
   PA 28—Analysis of Employment Information.
   PA 28-S—Employable Index Card.
   PA 40—Report of Epthamological Examination.
   PA 41—Report of Medical Examination.
   PA 41-D—Report of Medical Examination—Domiciliary Care.
   PA 41-S—Medical Supplement.
   PA 44—Burial Reserve Agreement.
   PA 48—Authorization for Services and Supplies.
   PA 50—Request for Appointment of Guardian, Representative, or Trustee.
   PA 50-P—Agreement (Public Nursing Home Care Program).
   PA 51—Request and Report State Mental Institutions.
   PA 52—Application-Foster Child Care.
   PA 52-C—Notice of Change in Eligibility for Foster Care Payment.
   PA 52-F—Child Welfare Service Agreement.
   PA 52-R—Annual Report-Foster Child Care.
   PA 53—PA Foster Home and Institutional Care Payment Report.
   PA 53-S—Summary Invoice for Foster Home and Institutional Care Payment Report.
   PA 54—Clearance of Mismatches-Enumeration Process.
   PA 57—Institution Agreement.
   PA 60-P—Medical Report Pulmonary.
   PA 61-S—Social Information Supplement.
   PA 62—Social Information for Aid to the Disabled Assistance.
   PA 72—Missing Relative Summary.
   PA 73—Request for Information.
   PA 75—Employer’s File Card.
   PA 76—Request for Financial Information.
   PA 78—Request for Confidential Employment Information.
   PA 79—Request for Legal Information.
   PA 83-Z—Request for Insurance Data.
   PA 84—Request for Information from Unemployment Records.
   PA 84-M—Request for Information Bureau of Motor Vehicles.
   PA 84-R—Authorization and Request for Information Railroad Retirement Board.
   PA 84-V—Request for Verification of Birth.
   PA 84-W—Request for Workmen’s Compensation Information.
   PA 85—Case Message.
   PA 87—Alphabetical Index Card.
   PA 88—Geographical Index File Card.
   PA 89—Cross Reference Card.
   PA 90—Application Control Card.
   PA 90-M—Medical Application Control Card.
   PA 91—Master Index File Information Only Card.
   PA 93—Sample Data Report on Medical Assistance.
   PA 94—Case Record Request.
   PA 95—Caseworker Notice.
   PA 95-N—General Control Notice.
   PA 96—Quality Control Card.
   PA 96-S—Quality Control Card Supplement.
   PA 117—Monthly Report on Medical Exams and Hearing to Determine Exempt Status.
   PA 118—Burial Request-Invoice.
   PA 122—Authorization for Assistance.
   PA 122-E—CBA Disbursement Authorization.
   PA 122-N—Authorization for Nursing Home Care.
   PA 122-PC—Petty Cash Voucher.
   PA 122-R—Authorization to Vendor.
   PA 122 Turnaround—Authorization for Assistance.
   PA 123-E—County Disbursement Notice of Credit.
   PA 124—NMP Authorization Card.
   PA 124-C—NMP Closing Card.
   PA 127—Report of Applications Other than MA (T).
   PA 127-M—Report of Applications Medical Assistance.
   PA 128—Report of Employable Persons.
   PA 153-A—Temporary Recording Sheet.
   PA 157—Report of Exception-County Reply.
   PA 162—Notice to Applicant.
   PA 162-A—Advance Notice.
   PA 162-C—Confirming Notice.
   PA 162-D—Notice to Applicant for Domiciliary Care.
   PA 162-M—Eligibility-Medical Assistance.
   PA 162-S—Discontinuance Authorization.
   PA 163—Request for Address and/or Amount of Assistance.
   PA 173-B—Referral for Support Action.
   PA 173-C—Application for Unadjusted Assistance Grant and Authorization to Pay Support Order Payments to the Department of Human Services.
   PA 173-D—Stipulation to Change Beneficiary.
   PA 173-E—Authorization to Change Beneficiary and to Pay Order and Arrearages to DHS.
   PA 173-F—Notice of Support Referral.
   PA 173-K—Agreement and Authorization to Pay Claim.
   PA 173-M—Medical Assistance Referral for Court Action.
   PA 173-S—Reimbursement Referral.
   PA 176-K—Agreement and Authorization to Pay Claim.
   PA 176-KM—Agreement and Authorization to Pay Medical Assistance Claim.
   PA 176-S—Reimbursement Authorization.
   PA 176-U—Agreement to Pay Claim—Delayed UC Checks.
   PA 184-S—Suggestion of Non-Payment.
   PA 189—Overpayment Referral.
   PA 189-A—Suspected Grant Referral Disposition Notice.
   PA 189-R—Claim Settlement Report on Referral.
   PA 189-X—Overpayment Investigation Control.
   PA 198—Assignment Receipt.
   PA 198-S—Assignment of Interest in Decedent’s Estate.
   PA 205—Notice of Returned Check.
   PA 205-S—Notice of Suspension.
   PA 207—Request for: Investigation of Check and/or Waiver of Investigation of Check.
   PA 207-DP—Authorization Correction Notice.
   PA 210—Referral to County Administrator.
   PA 212—Notice of Appointment with County Administrator.
   PA 213—Progress Report.
   PA 214—Monthly Report of Advancements, Expenditures and Balances Emergency Fund.
   PA 258-N—Request for NHC Payment.
   PA 259—Standard Medical Invoice.
   PA 259-C—Request for Correction of Payment Medical Assistance.
   PA 250-NS—Nursing Invoice.
   PA 259-P—Institutional Care Invoice Certification.
   PA 259-S—Invoice Transmittal.
   PA 260-F—Recommendation by County Review Team.
   PA 293—Child Support Action Notice.
   PA 295—School Medical Referral.
   PA 296—Social Security Number Consent Statement.
   PA 340—Application for Assistance.
   PA 364—Retirement Check Transmittal.
   PA 408—Verification of Social Security Number.
   PA 409—Enumeration—Clerical Control Sheet.
   PA 430—Medical Eligibility Authorization.
   PA 451—Report of Personal Interview.
   PA 653—Notice of Caseworker Change.
   PA 740—Face Sheet.
   PA 742—Income/Change Sheet.
   PA 743—Eligibility Form.
   PA 743-C—Eligibility Form.
   PA 743-R—Eligibility Form.
   PA 743-RE—Eligibility Form.
   PA 743-S—Rights and Responsibilities.
   PA 745—Domiciliary Care Redetermination Report.
   PA 746—Termination State Supplement for Domiciliary Care.
   PA 747—Authorization State Supplement for Domiciliary Care.
   PW 361—Standard Transmittal.
   PW 361-S—Standard Transmittal Supplement.
   PW-SS 205—SSA referral and disposition of services.
   SAU-2—IMU Allowance Request.
   SAU-3—Monthly Referral/Registration Activity.
   SAU-4—SAU Certification Record.
   SRS117A—WIN Certification Report.
   SRS 117B—AFDC WIN Grant Reductions Report.
   SS-5—Application for a Social Security Number.
   SSA-5—Application for Social Security Number.
   SSA 1610—Request for Information from SSA.
   SSA 8036—Notice of SSI Eligibility.
   SSA 8220—SSA State SSI Information Exchange Form.
   UC-46—Status of Overpayment.

Source

   The provisions of this §  101.5 amended July 11, 1986, effective July 12, 1986, 16 Pa.B. 2524. Immediately preceding text appears at serial pages (28853) to (28857) and (96061).
CHAPTER 103. DEFINITIONS

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