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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 County Assistance Office Name, District Office Name, Assessment Agency, and Date.
Proceed to the 'Applicant/Recipient Demographic Information' section. Fill in the Last Name, First Name, Address, City, State, Zip Code, Date of Birth, Telephone Number, and Social Security Number.
In the 'Eligibility / Program Assessment Information' section, check whether the individual meets eligibility criteria for Home and Community Based Services (HCBS) and provide relevant dates.
Complete the 'Agency Information' section by entering details about the enrolling agency and contact person.
If applicable, fill out sections regarding current residency in a long-term care facility or any changes in address or financial status.
Review all entered information for accuracy before saving your changes.

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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.

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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))

Pa 1768 form 2010-2026

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