Get Pa Hcbs Form Pa 1768 2010-2025

Filling out the PA HCBS Form PA 1768 is an essential step for individuals seeking Home and Community Based Services (HCBS) eligibility. This guide will help users navigate the form with clear and supportive instructions, ensuring accurate completion.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the PA HCBS Form PA 1768 and open it for editing.
2. Enter the office information, including the name of the county assistance office and the district office name. Provide the assessment agency name and the date of submission.
3. Fill out the applicant or recipient demographic information. This includes entering the last name, first name, address, city, state, zip code, date of birth, telephone number, and social security number. Include the name and phone number of the applicant’s representative if applicable.
4. Complete the eligibility and program assessment information. Indicate whether the individual meets the level of care by checking the appropriate box and entering the assessment date and service begin date.
5. Select the appropriate options regarding being a new applicant, change, transfer, or termination. Check which HCBS or Money Follows the Person (MFP) program applies.
6. Provide agency information by entering the enrolling agency contact person’s name, telephone number, agency name and address, fax number, and email.
7. Fill in the individual identification information including name and MA record number. Indicate if the individual is currently residing in or was admitted to a long-term care (LTC) facility.
8. If applicable, provide the date of discharge or admission, LTC facility name, and the HCBS program being applied for.
9. Complete the change of address or county residence information if the individual has moved, including dates and new addresses.
10. If transferring HCBS programs, provide the current and new program names along with service end and begin dates.
11. Complete any additional information regarding the program withdrawal or termination, and document any changes related to the individual's financial status.
12. Once all fields are filled, save your changes. You can then download, print, or share the form as necessary.

Begin filling out the PA HCBS Form PA 1768 online to ensure a smooth application process for Home and Community Based Services.