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

The Office of Medical Assistance Programs (OMAP) produces and distributes over 70 forms and envelopes for use at no charge to Medicaid providers. There may be a limit to how many forms can be ordered at one time.</p>

You must provide proof of your self-employment using the MAWD Self-Employment Form (PA 1762) or by submitting other records such as business plans, business records and ledgers; customer lists; proof of taxes paid; and/or a log of hours worked or jobs performed. A sample self-employment job log can be found at the end of this manual.

Note: Please know that all fill-in PDF forms should be downloaded and saved to your computer or device before you start entering information. This is the easiest way to electronically fill out the forms and prevent losing any information that you’ve entered.

complete an Employability Assessment Form (PA 1663) indicating the applicant’s temporary disability impacting their ability to work. • Adults who require Health Sustaining Medications (GA-related NMP) – a doctor should complete a Health-Sustaining Medication Assessment Form (PA 1671) indicating that the applicant needs medications to be ...

Revisions to the GA disability requirements under Act 35 precipitated the development of the following forms: * PA 1663--Employability Assessment Form * PA 1664--Employability Reassessment Form * PA 1671--Health Sustaining Medication Assessment Form * PA 1672--Drug and Alcohol Treatment Information Form. Effective Date

The document is a Health-Sustaining Medication Assessment Form from the Pennsylvania Department of Human Services, designed to evaluate whether an applicant or recipient requires medication to maintain employability.