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Get PA HD01582F 2015-2022

Egarding program eligibility requirements, income limits, or covered services, go to www.health.pa.gov/spbp. For questions about the application or enrolling, call 1-800-922-9384 or send your questions to SPBP@pa.gov. 1 Applicant Information Last name First name Middle initial Suffix (Sr., Jr., etc.) SPBP ID number (if known) English Spanish Other Preferred language Home address Include proof of residency with your application. City State Zip Provide your preferred mailing address.

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