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PA 1671 (SG) 04/
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE
HEALTH-SUSTAINING MEDICATION ASSESSMENT FORM
CASE IDENTIFICATION CO RECORD NUMBER CAT CSLD DIST
RECORD NAME DATE
CAO NAME AND ADDRESS
APPLICANT/RECIPIENT NAME: WORKER:
Does the applicant/recipient need health-sustaining medication? Yes No If no, you do not need to enter any further information. Just sign and date. If Yes, complete the following information.
Diagnosis:
Medication(s) needed for the APPLICANT/RECIPIENT to sustain employment based on the above diagnosis:
Explain why the APPLICANT/RECIPIENT cannot work in any capacity without this medication. ( Please be specific )
MEDICAL PROVIDER: TELEPHONE NUMBER:
ADDRESS:
SIGNATURE DATE
I HEREBY AUTHORIZE ALL MEDICAL PROVIDERS, INDIVIDUAL OR FACILITY OF WHATEVER TYPE, INCLUDING MENTAL HEALTH AND DRUG OR ALCOHOL TREATMENT TO RELEASE ALL MEDICAL/CLINICAL INFORMATION TO THE PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE (DPW) WHICH RELATES TO MY ABILITY TO WORK.
X (SIGNATURE) PRINTED NAME DATE PUBLIC ASSISTANCE APPLICANT/RECIPIENT
This form is to be completed for the applicant/recipient who requires medication that allows the person to be employable or continue with employment. All items in this section must be completed by a licensed prescriber and signed by both the physician and applicant/recipient.
See Reverse Side For Instructions
COMPLETION INSTRUCTIONS
HEALTH–SUSTAINING MEDICATION ASSESSMENT FORM
READ INSTRUCTIONS CONTAINING SPECIFIC DEFINITIONS AND REQUIREMENTS BEFORE
COMPLETING THE FORM
Medical information is required by the Department of Public Welfare (DPW) in determining whether an applicant qualifies for a certain category of public assistance benefits as well as his or her employability. Your medical assessment and documentation are necessary to help the CAO make these decisions.
Who may complete The assessment may only be completed by the following licensed medical providers: the assessment: physician, physician-assistant, certified registered nurse practitioner, or psychologist.
Who signs the form: Only the individual who completed the employability assessment may complete and sign the form. Signature or clinic stamps, labels, and other facsimiles are not acceptable. The signature must be original or the form will be invalidated.
General form The information on the form and attachments must be legible. The inability of county completion staff to read your material will result in the client’s application being delayed and the form requirements: being returned to you for clarification. If at all possible, the form and any attachments should be typed. If all questions are not answered fully, the client’s application will be delayed and the form returned to you for completion.
Diagnosis: Record your diagnosis of the applicant/recipient’s condition. The explanation should indicate whether or not the condition is chronic or temporary. Attach documentation sufficient to support your decision such as medical records, X-rays, and lab reports that support your conclusion must be attached. Simply providing a diagnosis is not sufficient. Without this documentation, the client will be determined ineligible for benefits.
Medication Needed: List the medication(s) needed by the applicant/recipient that address his medical condition thus enabling him/her to be able to work.
Explanation: Explain in detail what the consequences to the applicant/recipient would be if the medication(s) listed above were not available to him/her. Document in this section whether the medication is for a chronic condition such as diabetes that the person will be required to take for life. Also indicate if the medication will be needed for a limited time period. If that is the case, show the date the person is expected to no longer need the medication.
Questions: Contact your local County Assistance Office at:
