Pa 1671 form-2026

1. Click ‘Get Form’ to open the PA 1671 form in the editor.
2. Begin by entering the CAO name and address, along with case identification details such as record number and date.
3. In the applicant/recipient section, fill in the name of the individual requiring health-sustaining medication.
4. Indicate whether the applicant/recipient needs health-sustaining medication by selecting 'Yes' or 'No'. If 'No', simply sign and date the form.
5. If 'Yes', provide a detailed diagnosis and list all necessary medications that enable employment. Be specific about how these medications impact employability.
6. Complete the medical provider's information, including their name, telephone number, and address. Ensure they sign and date the form.
7. Finally, authorize medical providers to release relevant information by signing at the bottom of the form.

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