Pennsylvania’s PA 1921 SNAP medical exemption form is the one-page document your medical provider signs to confirm that a physical or mental condition keeps you from meeting SNAP work requirements, so your food assistance continues without the usual work, volunteering, or training hours. You complete the top section and sign the release, your provider completes the medical questions, and you return the form to the Department of Human Services through COMPASS, your County Assistance Office, mail, or fax.
When You Actually Need This Form
SNAP work rules apply if you are 18 to 64, have no dependent child under 14, and are considered physically and mentally able to work. If that describes you, you must work, volunteer, or participate in education or training for at least 20 hours per week (80 hours per month) and report that activity to DHS, or your benefits can be cut off.1Pennsylvania Department of Human Services. SNAP Work Requirements
The PA 1921 is how you document that a health condition prevents you from meeting those hours. Before you go to the trouble of getting it filled out, check whether another exemption already covers you. DHS also exempts people who are pregnant, homeless, in a drug or alcohol treatment program, caring for an ill or disabled household member, receiving Unemployment Compensation, or survivors of domestic violence.1Pennsylvania Department of Human Services. SNAP Work Requirements If one of those fits your situation, you may not need the PA 1921 at all.
Postsecondary students enrolled at least half-time can also use the form, through a separate question, to document a qualifying disability for SNAP eligibility.2Pennsylvania Department of Human Services. PA 1921 SNAP Medical Exemption Form
Where to Get the Form and What to Have Ready
You can download the PA 1921 PDF from the DHS SNAP work requirements page, listed under “Tools and Resources.”1Pennsylvania Department of Human Services. SNAP Work Requirements If you don’t have a printer, pick one up at any County Assistance Office; the DHS directory at pa.gov lists every CAO location.3Pennsylvania Department of Human Services. County Assistance Offices
Before your appointment, gather:
- Your full name and date of birth as they appear on your SNAP case.
- Your DHS case number, which is printed on correspondence from the Department.
- A medical provider willing to complete and sign the form.
Who Can Sign the Medical Section
DHS accepts the PA 1921 from a much broader range of professionals than just your primary care doctor. The form lists these as qualified to complete the medical questions:
- Physician, physician’s assistant, or a designated representative of the physician’s office
- Nurse practitioner or midwife
- Osteopath or podiatrist
- Psychologist, mental health counselor, or social worker
- Drug and alcohol abuse counselor
- Audiologist, physical therapist, or occupational therapist
- Optometrist
- Any other medical professional whose services are reimbursable by Medical Assistance
That last line matters. If you see a specialist not named on the list but whose care Pennsylvania Medical Assistance covers, that provider can still sign.2Pennsylvania Department of Human Services. PA 1921 SNAP Medical Exemption Form
How to Fill Out the Form
The PA 1921 has two parts. You handle the first; your provider handles the rest.
Your Section
Print your name, date of birth, and DHS case number in the spaces at the top. Then read the authorization statement, which gives your provider permission to release medical information to DHS. Sign and date it. Without your signature, DHS cannot process the exemption, and this is the single most common reason forms come back.
Provider Section (Questions 1 and 2)
Your provider answers the clinical questions: whether you have a physical or mental condition that reduces your ability to work, and whether you are currently in a treatment or rehabilitation program. They specify the nature of the condition and whether it is temporary or permanent. If temporary, they estimate how long the limitation will last. The provider then prints their name, title, and contact information, and signs and dates the form. A missing signature or date will get the form kicked back, so check both fields before you leave the office.
Question 3 (Students Only)
Question 3 applies only to students enrolled at least half-time at a postsecondary institution. It asks whether you currently receive reasonable accommodations from the school’s disability access office. A school official familiar with your services, such as a disability services coordinator, can answer this question in place of a medical provider.2Pennsylvania Department of Human Services. PA 1921 SNAP Medical Exemption Form If you are not a student, skip it. If a medical condition also keeps you from meeting ABAWD work hours, your provider should still complete Questions 1 and 2.
How to Submit the Signed Form
You have several ways to get the completed form to DHS:
- COMPASS online portal: log into your account at compass.dhs.pa.gov and upload a scan or clear photo of the signed form. The MyCOMPASS PA mobile app accepts uploads straight from your phone.4Pennsylvania Department of Human Services. COMPASS
- County Assistance Office drop box: bring the form to your local CAO without needing an appointment.3Pennsylvania Department of Human Services. County Assistance Offices
- Mail: send it to the CAO that manages your case, using the address on your most recent DHS correspondence.
- Fax: use the fax number listed for your specific CAO on the DHS directory.
Keep a copy either way. If you drop the form off in person, ask for a date-stamped receipt. Proof of submission protects you if the paperwork gets lost.
What Happens Next
Most applications and related paperwork are reviewed within 30 days once assigned to a caseworker.5Commonwealth of Pennsylvania. Track Your LIHEAP, Medicaid, SNAP, and TANF Applications If the medical information is incomplete or unclear, DHS may contact you or your provider for more detail. Respond quickly; delays can lead to a denial.
DHS mails a written decision to your address on file. The notice says whether the work requirement is waived and, if so, how long the exemption lasts. If you’re denied, the notice explains why and tells you how to appeal. For SNAP cases, you can appeal either in writing or orally with the DHS office that made the decision, and the deadline is stated in the denial notice itself.6Pennsylvania Department of Human Services. Request a Hearing or Appeal from DHS
Renewing a Temporary Exemption
If your provider marked the condition as temporary, the exemption only lasts for the duration they wrote on the form. When that time runs out, the work requirement starts applying to you again. If your condition hasn’t improved, submit a new PA 1921 with an updated assessment before the current exemption expires. Get the form to your provider a few weeks early to avoid a gap.
A permanent certification doesn’t need the same periodic renewal, but DHS may still review your case at regular SNAP recertification. If a recertification packet arrives, make sure your medical exemption is noted and respond by the stated deadline.
A Word on False Information
Deliberately putting false medical information on the PA 1921, or any SNAP form, can lead DHS to find an Intentional Program Violation, which brings a 12-month loss of benefits on a first violation, longer periods for repeat violations, and permanent disqualification for a third. States can also pursue fraud charges separately. An honest mistake or a misunderstood question is not an IPV, though you may still have to repay benefits you weren’t entitled to. If any part of the form confuses you, ask your caseworker before you submit.
Not the Same as the Medical Expense Deduction
The PA 1921 is often confused with the SNAP medical expense deduction, but they are separate. The deduction is for households that include someone 60 or older or someone with a disability, and it lets them subtract unreimbursed medical costs over $35 per month from countable income, which can raise their monthly benefit.7Food and Nutrition Service. SNAP Medical Expenses Handbook If both apply to you, use the PA 1921 for the work exemption and report medical expenses separately through your caseworker or at recertification. Qualifying for one doesn’t automatically give you the other.