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Click ‘Get Form’ to open the PA 1768 form in the editor.
Begin by filling out the Office Information section. Enter the District Office Name, County Assistance Office Name, and Date.
In the Applicant/Recipient Demographic Information section, provide the First Name, Last Name, Address, City, State, Zip Code, Date of Birth, Telephone Number, and Social Security Number.
Complete the Eligibility/Program Assessment Information by checking whether the individual meets or does not meet the level of care for Home and Community Based Services (HCBS). Include relevant dates.
Fill in 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 indicated on the form.

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What is the 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))

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 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