Forms and Applications

Welcome to the DPW document warehouse for applications and forms. If you cannot find a document, please Contact DPW

DPW Forms

• Act 21 Forms
• Attendant Care Waiver Applications
• Benefits Review (PDF download)
• Cash Assistance Application (PDF download; or apply online using COMPASS)
• Child Abuse History Clearance Forms
• Child Care Forms
• Eligibility for Long Term Care Facilities (PDF download)
• Food Stamps Application (PDF download; or apply online using COMPASS)
• Health Care Coverage and CHIP Application (PDF download)
• HIPAA Authorization for Use or Disclosure of Personal Information
• Medical Assistance/Medicaid Application (PDF download; or apply online using COMPASS)
• Medical Assistance/Medicaid health care coverage for those with disabilities who are employed (PDF download)
• Medical Assistance Forms
• Medicare Part B Premium for Elderly or Disabled (PDF download)
• Personal Care Homes Required Forms
• Prioritization of Urgency of Need for Services (PUNS) Form
• State Police Request for Criminal Record Check Form

Other Resources:

CY 130 - Child Registration/Update Form (Resource Family Applicant: Registration/Update Form; PDF download)
PA 1768 - Home and Community Based Services (HCBS) Eligibility/Ineligibility/ Change Form (PDF download)
Complaint Form (PDF Download)
Application for SelectPlan for Women (PA 600 SP) (PDF Download)
Permission to Evaluate Form (PDF Download)

Version Espanola

• Asistencia en efectivo (Transferencia directa del pdf)
• Beneficios de cupones de alimentos (Transferencia directa del pdf)
• Asistencia medica (Transferencia directa del pdf)
• Autorizacion para utilizar o divulgar informacion personal
• Priorizacion de la urgencia de la necesidad de servicios (PUNS)
• Solicitud de la cobertura medica (Transferencia directa del pdf)
• Solicitud de elegibildad financiera de la asistencia medica (Medicaid) para laatencion, apoyosy serviciosa largoplazo (Transferencia directa del pdf)
• Solicitud para ser enviada por correo para el pago de la prima de la Part B de Medicare (Transferencia directa del pdf)
• Solicitud para el plan SelectPlan for Women