Pa 1768 form-2025

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The document is a form for Home and Community Based Services (HCBS) that captures eligibility, ineligibility, and changes in status for applicants or recipients. It includes sections for demographic information, assessment details, agency contact information, and various options for changes such as transfers or terminations of services. The form is designed to facilitate the application process and ensure proper documentation of an individual's eligibility for HCBS.

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Click ‘Get Form’ to open the PA 1768 in the editor.
Begin by filling out the 'Office Information' section. Enter the County Assistance Office Name, District Office Name, Assessment Agency, and Date.
In the 'Applicant/Recipient Demographic Information' section, provide the applicant's last name, first name, address, city, state, zip code, date of birth, telephone number, and social security number.
Complete the 'Eligibility/Program Assessment Information' by checking the appropriate boxes for eligibility status and entering relevant dates for assessment and service begin.
Fill in the 'Agency Information' with details about the enrolling agency contact person and their contact information.
If applicable, complete sections regarding changes in address or financial status as needed. Ensure all required fields are filled accurately.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (98 Votes)
2019	4.3 Satisfied (36 Votes)
2019	4.8 Satisfied (69 Votes)
2017	4.8 Satisfied (108 Votes)
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2010	4.9 Satisfied (481 Votes)

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What is a PA 1768 form?

PA 1768 ORIGINATOR PA 1768 Eligibility/Ineligibility/Change Form is being submitted by one of the following: Enrolling agency (HCBS provider, county mental health/intellectual. disability (MH/ID) program, or independent enrollment broker (IEB)/ Area Agency on Aging (AAA)) Service Coordinator (SC)

Who completes a PA 1768 form?

Enrolling agency (HCBS provider, county mental health/intellectual disability (MH/ID) program, or independent enrollment broker (IEB)/Area Agency on Aging (AAA)) submits initial PA 1768; or Service Coordinator (SC) can report updates, changes, and terminations; or Additional entity requiring 162 notification may also

Who is authorized to administer oaths in PA?

Oaths and acknowledgments. (a) General ability. --Each judicial officer, each clerk of court, each retired or senior judge and such other personnel of the system and jurors as may be designated by or pursuant to general rules may administer oaths and affirmations and take acknowledgments.

What is a PA 1768?

The HCBS Eligibility/Ineligibility/Change Form (PA 1768) is the only form the CAOs will receive to document program eligibility for an HCBS Program or any other changes in the individuals status for an HCBS Program. DISCUSSION.