55 Pa. Code § 101.5
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.
55 Pa. Code § 101.5