PENNSYLVANIA

Application for Medical Assistance for

Workers with Disabilities

Medical Assistance for Workers with Disabilities (MAWD) offers health care coverage for individuals with
disabilities who are employed. There may be a nominal fee for this coverage.

If you have a disability and need this form in large print or another format, please call our
helpline at 1-800-692-7462. TDD services are available at 1-800-451-5886.
This is an application for Medical Assistance benefits. If
you need help translating it, please contact your county
assistance office, CAO. Translation services will be
provided free of charge.
Esta es una solicitud de beneficious de Asistencia Mdica.
Si necesita ayuda con la traduccin comunquese con
la Oficina de Asistencia del Condado (CAO) que le
corresponde. Los servicios de traduccin son gratuitos.

How Do I Qualify?

How Do I Apply?

1. You must be at least 16 years of age but less than

65 years of age.
2. Your countable resources such as bank accounts,
stocks, and bonds may not exceed $10,000.
3. Your countable income, after allowable deductions,
must be less than 250% of the Federal Poverty
Income Guideline.
4. You must meet the definition of a disability according
to the Social Security Administration. To meet the
definition of a disability, you must meet one of the
following:
o You must be currently receiving Social Security
Disability Insurance (SSDI).
o You must have received Supplemental Security
Income, SSI or SSDI, within the past 12 months.
o If you do not meet either of the above conditions,
the department will review your disability to
determine if it meets the qualifying criteria.
5. You must also be employed and receiving
compensation to receive coverage as a Worker
with a Disability.

1. Complete the enclosed application. (If you need

help, call the Helpline at 1-800-842-2020 or TDD
1-800-451-5886 for the hearing impaired.) You can
also contact your local county assistance office, or
CAO, or check the DPW website at www.dpw.state.
pa.us. You can also apply online at
www.compass.state.pa.us.
2. Attach proof of your income, impairment-related
work expenses, resources, social security number,
address, and identification.
3. Read the Rights and Responsibilities section and
sign the application.
4. Mail the application to your CAO. A staff member
from the CAO will contact you if additional
information is needed. The CAO will inform you of
your eligibility for benefits.
If you need cash assistance or SNAP, you
must complete a different application.
Please call your county assistance office
and they will send you the proper form.

PA 600 WD (SG) 8/12

Client Rights and Responsibilities

Right to Non-discrimination

In accordance with Federal law and U.S. Department of Health and Human Services, or HHS, Policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, or disability. To file a complaint of discrimination, contact HHS. Write
HHS, Director, Office of Civil Rights, Room 506-F, 200 Independence Avenue, S. W. Washington, D.C. 20201 or call
(202) 619-0403 (Voice) or (202) 619-3257 (TTD). HHS is an equal opportunity provider and employer.

Right to Confidentiality

We keep information you give confidential and use it only to administer the programs you apply for and/or may be eligible for.

Right to a Written Notice

P
Y

We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on
the notice. You have 30 days from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons
given.

Right to Appeal

You have the right to ask for a departmental hearing to appeal a decision of or a failure to act by the department which affects your
benefits or that you feel is unfair or incorrect. You may file the appeal at the CAO. At the appeal hearing, you may represent yourself,
or someone else, such as a lawyer, friend or relative, may represent you. You may have an agency conference before the hearing.

Right to Certificate of Creditable Coverage

Responsibility to provide Social Security Numbers

You have a right to a certificate of coverage to verify your medical coverage. Federal law limits when health care coverage may be denied
or limited for a pre-existing condition. If you enroll in a health plan that allows for a pre-existing condition, exclusion or limitation, you may
get credit for the time you received Medical Assistance.

Responsibility to Provide Information

You must provide a Social Security number, or SSN for each person for whom you are applying. If you do not have a SSN, we will
help you apply for one. Refusal or failure to provide an SSN may result in ineligiblity. We will also ask you to supply a SSN to verify
identity and administer our programs. We will use your SSN to prevent duplication in state and federal programs and to get information
about income to determine eligibility for benefits.

E
N

You must give true, correct and complete information. You must cooperate in documenting or proving the information you give.
If you cannot provide proof, you should ask the CAO to help. You must cooperate fully with persons or investigators of Department of
Public Welfare, DPW, or Office of Inspector General conducting investigations.

Responsibility to Report Changes

LI

You must report changes in the number of people in your household, address, new unearned income, real property or other resources
(such as bank accounts or life insurance). You must report any plans to leave the state, even temporarily. You must report if your
gross monthly earned income increases by more than $100. If you have unearned income, you must report if your gross monthly
unearned income increases by more than $50. You can report changes to the CAO in person, by telephone, by fax or by mail.
Changes must be reported within the first 10 days of the month following the month of the change.

Responsibility to use the PA ACCESS Card Lawfully

You may use the PA ACCESS card for the services only during the period you are eligible. You must use the card only for the person
who is eligible and you may get only the services that are needed and reasonable.

Responsibility to Pay Monthly Premium

You are responsible for the payment of your monthly premium. If you do not pay your premium timely, you may lose your health
coverage.

If You Cannot Pay Your Premium

Your monthly premium can be waived for reasons such as ongoing health problems, layoff or loss of employment, discrimination, or
other factors beyond your control. You must also intend to return to the former position or be making a bona fide effort to seek other
employment.

Responsibility to Contact Providers for Refunds

If you pay for any medical bills between the date of application and the determination of your eligibility, you are responsible for contacting
the provider for a refund.

ii

COUNTY ASSISTANCE OFFICE USE ONLY

AUTHORIZED UNAUTHORIZED

n
MAIL n
WALK IN

FILE CLEAR BY/DATE

SCREEN BY/DATE

DATE

COUNTY DISTRICT

APPLICATION REG. NUMBER

DATE STAMP

BY

WORKER ID CASE LOAD RECORD NUMBER

CAT

CAT

NAME

APPOINTMENT DATE/TIME n AM REASON CODE

n
PM

TELL US ABOUT YOU, THE PERSON APPLYING

YOUR NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

ADDRESS

STATE

ZIP CODE

TELEPHONE NUMBER

TOWNSHIP (CIVIL SUBDIVISION)

SCHOOL DISTRICT

Are you receiving Social Security Disability Insurance (SSDI) benefits?

n Yes

n No

PLUS 4

n Dont Know

If no, tell us about your disability and provide documentation.

When filling out this application, please attach separate sheets if additional
space is needed.

Voter Registration (Optional)

If you are not registered to vote where you live now, would you like to apply to register to vote here today?
Yes
No
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
To register, you must: 1) Be at least 18 on the day of the next election; 2) Be a citizen of the United States for at least one month
PRIOR TO THE NEXT ELECTION; 3) Reside in Pennsylvania and the voting district at least 30 days prior to the next election.
Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.
If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is
yours. You may fill out the application form in private. Please contact the county assistance office if you would like help. If you believe that
someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in
applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the
Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-free telephone number 1-877-VOTESPA.)

COUNTY ASSISTANCE OFFICE STAFF WILL COMPLETE THIS BOX BASED ON YOUR RESPONSE ABOVE
n
Given to Client __/__/__
n
Declined, not interested __/__/__

n
Sent to voter registration __/__/__ n
Mailed to Client __/__/__
n
Not a U.S. citizen __/__/__
n
Declined, already registered __/__/__

PA 600 WD (SG) 8/12

1. HOUSEHOLD, CITIZENSHIP, AND IDENTITY INFORMATION

Please list the people who live with you, starting with yourself. Make sure you look below for the application Race
Code (the race code is optional and for statistical purposes only, and has no affect on your eligibility for benefits)
and Citizenship Code. Attach additional sheets if needed.
Do you understand English? n
Yes n
No If no, what language(s) do you understand?
____________________________________________________________________________________________
____________________________________________________________________________________________
CITIZENSHIP: Use one of the following codes:

1. US Citizen
2. Permanent Alien
3. Temporary Alien
5. Undocumented Alien 6. Refugee Unaccompanied Minor

4. Refugee

FOR RACE (Optional): Use any of the following codes that apply. Your benefits will not be affected if you do not answer. Individuals may fit more than one group.
1. Black 2. Hispanic 3. North American Indian or Alaskan Native 4. Asian 5. White (Not Hispanic) 6. Other 7. Native Hawaiian or Pacific Islander
NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

NAME ON BIRTH CERTIFICATE (Last, First, M.I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

n
Male n
Female

n
Yes n
No
MOTHERS MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Access Card?

Drivers License (State & Number) or State ID No. Relationship of Applicant to You

n
Yes n
No

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

NAME ON BIRTH CERTIFICATE (Last, First, M.I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

MOTHERS MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Access Card?

Drivers License (State & Number) or State ID No. Relationship of Applicant to You

n
Male n
Female

n
Yes n
No

n
Yes n
No

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

NAME ON BIRTH CERTIFICATE (Last, First, M. I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

MOTHERS MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Access Card?

Drivers License (State & Number) or State ID No. Relationship of Applicant to You

n
Male n
Female

n
Yes n
No

n
Yes n
No

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

NAME ON BIRTH CERTIFICATE (Last, First, M. I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

MOTHERS MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Access Card?

Drivers License (State & Number) or State ID No. Relationship of Applicant to You

n
Male n
Female

n
Yes n
No

n
Yes n
No

NAME (Last, First, Middle Initial)

Jr./Sr., etc.

Date of Birth

Sex

Social Security Number

Medicare Claim Number

NAME ON BIRTH CERTIFICATE (Last, First, M. I.)

State of Birth

County of Birth

City of Birth

Alien Registration Number

Are You Applying for this Person?

MOTHERS MAIDEN NAME (First, Last)

Race Code

Citizenship Code

Does This Person Have A Pa

Access Card?

Drivers License (State & Number) or State ID No. Relationship of Applicant to You

n
Male n
Female

n
Yes n
No

n
Yes n
No

2. INCOME
Please tell us if anyone listed on this application has, or is expecting any type of income. List the income amount before deductions
(such as taxes or insurance) are taken out. Income includes but is not limited to:
o Wages
o Baby Sitting
o Rent
o Veterans Benefits o Sick Benefits
o Dividends or Interest
o Self-Employment o Room and Board o Social Security/SSI o Support or Alimony o Unemployment or Workers Compensation
o Pensions
o Commissions
o Money for College or Training
EMPLOYER OR
SOURCE OF INCOME

NAME

HOURS WORKED
PER WEEK

HOURLY
WAGE

EMPLOYERS ADDRESS

TELEPHONE

HOW OFTEN IS INCOME RECIEVED?

(CIRCLE ONE)

GROSS AMOUNT
BEFORE DEDUCTIONS

Weekly / Bi-weekly / Monthly / Other (explain)

Weekly / Bi-weekly / Monthly / Other (explain)
Weekly / Bi-weekly / Monthly / Other (explain)
Weekly / Bi-weekly / Monthly / Other (explain)
Weekly / Bi-weekly / Monthly / Other (explain)

3. EXPENSES
You may have spent money in order to receive income. If you did, please list the expense(s) below:
o Court Costs or Attorney Fees
o Transportation
o Impairment related work expenses
(such as medical devices, or attendant care)
NAME

AMOUNT

TYPE OF EXPENSE

HOW
OFTEN PAID

PA 600 WD (SG) 8/12

4. RESOURCES
Does anyone listed on this application have any of the following resources?
o Yes o No Cash-on-hand (01)
o Yes o No Savings Account (02)
o Yes o No Checking Account (03)
o Yes o No Christmas or Vacation Club (04)
o Yes o No Stocks or Bonds (05)
o Yes o No U.S. Savings Bonds (05)
NAME

o Yes o No Trust Fund (06)

o Yes o No Certificate of Deposit (26)
o Yes o No IRA, KEOGH, or other retirement plan (27)
o Yes o No Burial Reserves or Trusts (97)
o Yes o No Non-resident Property (98)

DESCRIBE TYPE/ACCOUNT NUMBER/LOCATION OF THE RESOURCE

CURRENT VALUE

n
Yes n
No Is anyone listed on this application expecting money or any type of resource such as, but not limited to, an accident settlement, inheritance,
trust fund or other resource? If yes, type of resource: __________________ Value: ____________ Date expected: ___________________

n
Yes n
No Since February 8, 2006 have you or anyone listed on the application given away, sold or transferred any assets such as: a home, land,

personal property, life insurance policies, annuities, bank accounts, certificates of deposit, stocks, IRA, bonds or a right to income? If yes,
describe the type of property: __________________ Value: ____________ Date sold, transferred, or given away: ____________________

Does anyone listed on this application own or are they making payments on a vehicle (car, truck, motorcycle)? n
Yes n No
NAME

YEAR

MAKE

MODEL

LICENSED

AMOUNT OWED

n
Yes n
No
n
Yes n
No
n
Yes n
No

Does anyone listed on this application have a life insurance policy?

POLICY OWNER

NAME OF INSURANCE COMPANY/POLICY NUMBER

FACE VALUE

Does anyone listed on this application have health insurance besides Medical Assistance?
POLICY OWNER

NAME OF INSURANCE COMPANY/POLICY NUMBER

CASH VALUE

WHO IS COVERED?

n
Yes n
No
WHO IS COVERED?

5. BENEFITS FOR PREGNANT WOMEN

There are additional benefits which may be available to pregnant women. Complete this section if you want to make a referral for
someone in your household who is pregnant.
ADDRESS

NAME

PREGNANCY
DUE DATE

6. U.S. MILITARY SERVICE

n
Is anyone in the U.S. military, or has been in the U.S. military?
Yes n
No
Is anyone a widow, spouse, or child (under age 18) of anyone in the U.S. military, or anyone who has been in
n
the U.S. military?
Yes n
No
PERSON WHO SERVED

BRANCH (ARMY, NAVY, MARINE CORP, AIR FORCE, COAST GUARD)

DATES OF SERVICE

7. IF YOU HAVE UNPAID MEDICAL BILLS

If you have unpaid medical bills for up to three months before the application date, those bills could be covered.
This is called retroactive coverage. If you are determined eligible for retroactive coverage, you may be responsible for
premium payments for each retroactive month. Please note that your retroactive bills will not be covered until these premium
payments are received. If you think your bills might be less than the premium payment, you may not want to apply for
retroactive coverage. Complete the section below if you wish to be considered for retroactive coverage. Please list any
additional bills on a separate sheet of paper.
Please Note: You must submit verification of your income and resources for all months in which retroactive coverage is
requested.
DATE OF SERVICE

DATE OF SERVICE

HOSPITAL / DOCTOR / PRESCRIPTION

HOSPITAL / DOCTOR / PRESCRIPTION

AMOUNT OF BILL

AMOUNT OF BILL

PA 600 WD (SG) 8/12

8. ATTACH PROOF
We will need proof of the information you have provided to process your application. If you are unable to obtain
proof of the information, your CAO will help you.
n Check here if you need help getting proof of your address, income and/or resources.
Do you have copies of the information you provided?

n
Yes n
No

PLEASE SEND COPIES - NOT ORIGINALS

Identification (only one source)
Citizenship
Alien status (only if non-U.S. citizen)
Address (only one source)
Income
Resources

drivers license, passport, photo ID

birth certificate or passport
Most current immigration documents
rent receipt, utility bill, drivers license (with current address), mortgage bill or receipt,
post office records, tax records, etc.
One months current pay stub, proof of pension, Financial Eligibility Notice for Unemployment
Compensation, tax forms or other records of self-employment income, copies of check stubs
or statements from the source of income.
bank statements, insurance policies, Tax Assessment Notices

If you are unable to obtain proof of the information you have provided, the county assistance office will help you. Please
attach a note explaining why you are unable to provide the proof.

9. WHEN WILL BENEFITS BEGIN?

You may choose the month you want Medical Assistance to start. Check ()one of the boxes below:
n

Check () here and your eligibility will begin the month

of application. You will have to pay the premium
starting the month of application.

Check () here and your eligibility will begin the month

after application. You will have to pay the premium
starting the month after application.

10. HOW TO PAY THE PREMIUM

To participate in this program, you must pay a monthly premium. The preferred method of payment is payroll deduction.
With payroll deduction, your employer will deduct the monthly premium amount directly from your paycheck. Please check
the box below if you want payroll deduction.
n

YES, I want payroll deduction

If you are self-employed, do not want payroll deduction, or your employer doesnt offer payroll deduction, you will be
sent a monthly statement. You will be responsible for mailing that statement each month with your payment.
Please check the box below if you want a monthly statement, and do not want payroll deduction

NO, I do not want payroll deduction.

NOTE: In some cases, you may not be required to pay a premium.

11. YOUR RIGHTS AND RESPONSIBILITIES

RIGHT TO NON-DISCRIMINATION
In accordance with Federal law and U.S. Department of Health and Human Services, or HHS, Policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, or disability. To file a complaint of discrimination, contact HHS. Write
HHS, Director, Office of Civil Rights, Room 506-F, 200 Independence Avenue, S. W. Washington, D.C. 20201 or call (202) 619-0403
(Voice) or (202) 619-3257 (TTD). HHS is an equal opportunity provider and employer.

RIGHT TO CONFIDENTIALITY
We keep information you give confidential and use it only to administer the programs you apply for and/or may be eligible for.

RIGHT TO A WRITTEN NOTICE

We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on
the notice. You have 30 days from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons
given.

RIGHT TO APPEAL
You have the right to ask for a departmental hearing to appeal a decision of or a failure to act by the department which affects your
benefits or that you feel is unfair or incorrect. You may file the appeal at the CAO. At the appeal hearing, you may represent yourself,
or someone else, such as a lawyer, friend or relative, may represent you. You may have an agency conference before the hearing.

RIGHT TO CERTIFICATE OF CREDITABLE COVERAGE

You have a right to a certificate of coverage to verify your medical coverage. Federal law limits when health care coverage may be
denied or limited for a pre-existing condition. If you enroll in a health plan that allows for a pre-existing condition, exclusion or
limitation, you may get credit for the time you received Medical Assistance.

RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERS

You must provide a Social Security number, or SSN, for each person for whom you are applying. If you do not have an SSN, we will
help you apply for one. Refusal or failure to provide an SSN may result in ineligiblity. We will also ask you to supply an SSN to verify
identity and administer our programs. We will use your SSN to prevent duplication in state and federal programs and to get information
about income to determine eligibility for benefits.

RESPONSIBILITY TO PROVIDE INFORMATION

You must give true, correct and complete information. You must cooperate in documenting or proving the
information you give. If you cannot provide proof, you should ask the CAO to help. You must cooperate fully with
persons or investigators of DPW or Office of Inspector General conducting investigations.

RESPONSIBILITY TO REPORT CHANGES

You must report changes in the number of people in your household, address, new unearned income, real property
or other resources (such as bank accounts or life insurance). You must report any plans to leave the state, even
temporarily. You must report if your gross monthly earned income increases by more than $100. If you have
unearned income, you must report if your gross monthly unearned income increases by more than $50. You can
report changes to the CAO in person, by telephone, by fax or by mail. Changes must be reported within the first
10 days of the month following the month of the change.

RESPONSIBILITY TO USE THE PA ACCESS CARD LAWFULLY

You may use the PA ACCESS card for services only during the period you are eligible. You must use the card only
for the person who is eligible and you may get only the services that are needed and reasonable.

RESPONSIBILITY TO PAY MONTHLY PREMIUM

You are responsible for the payment of your monthly premium. If you do not pay your premium timely, you may
lose your health coverage.

IF YOU CANNOT PAY MONTHLY PREMIUM

Your monthly premium can be waived for reasons such as ongoing health problems, layoff or loss of employment,
discrimination, or other factors beyond your control. You must also intend to return to the former position or be
making a bona fide effort to seek other employment.

RESPONSIBILITY TO CONTACT PROVIDERS FOR REFUNDS

If you pay for any medical bills between the date of application and the determination of your eligibility, you are
responsible for contacting the provider for a refund.

PA 600 WD (SG) 8/12

12. AGREEMENT AND UNDERSTANDING

WHEN I SIGN THIS FORM I AGREE THAT:

WHEN I SIGN THIS FORM I UNDERSTAND THAT:

n I have read this application in full or someone has read it to

me and I understand the questions asked.

n If I do not report changes as required, my benefits may

be reduced or stopped. If I purposely fail to give correct
information or report changes, I may be fined and/or put in jail.

n I received a copy of my rights and responsibilities, have read

them or someone has read them to me, and I understand
them.

n The state operates a fraud control program under which local,

state, and federal officials may verify the information I have
given.

n I will provide or cooperate in getting any information needed to

prove my statements.

n The state may obtain information about my circumstances

from other persons or organizations, including computer
matches and Immigration and Naturalization.

n I must report any changes in my circumstances within the first

10 days of the month following the month of the change.

n My Social Security number will be used to obtain information

to verify my circumstances and eligibility.

n I am responsible for any fraudulent statements made on this

application even if the application is submitted by someone

acting on my behalf.

n I understand, that by signing below, I am certifying that the

persons I am applying for are U.S. citizens or aliens in lawful
immigration status.

n I certify that, subject to penalties provided by law, the

information I gave is true, correct, and complete to the best of
my knowledge.

CLIENT OR REPRESENTATIVE SIGNATURE

Signature of Client/Representative

Signature of Witness (if x used above)

Address of Client/Representative

Address of Witness

Telephone

Telephone

Date

Date

PA 600 WD (SG) 8/12