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Pa 1768 form 2010-2026
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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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| 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) | |
| 2016 | 4.8 Satisfied (238 Votes) | |
| 2016 | 4.8 Satisfied (145 Votes) | |
| 2016 | 4.8 Satisfied (114 Votes) | |
| 2016 | 4.3 Satisfied (176 Votes) | |
| 2016 | 4.5 Satisfied (53 Votes) | |
| 2016 | 4.1 Satisfied (20 Votes) | |
| 2014 | 4.8 Satisfied (178 Votes) | |
| 2011 | 4.2 Satisfied (51 Votes) | |
| 2011 | 4.8 Satisfied (61 Votes) | |
| 2011 | 4.8 Satisfied (86 Votes) | |
| 2010 | 4.9 Satisfied (481 Votes) |
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