The PA 1671 Health-Sustaining Medication Assessment Form is the Pennsylvania Department of Human Services document a medical provider completes to confirm you need prescription medication to stay employable. If the assessment is accepted, you may qualify for a limited Medical Assistance category that covers those medications. To use it, download the PDF from the DHS website or pick one up at your County Assistance Office, have a qualifying provider complete and sign the clinical section with supporting records attached, sign the applicant authorization yourself, and return the form to your local County Assistance Office.
Who Can Sign the Clinical Section
Only four provider types can complete the medical portion: a physician, a physician assistant, a certified registered nurse practitioner, or a psychologist.1Pennsylvania Department of Human Services. Health-Sustaining Medication Assessment Form2Pennsylvania Department of Human Services. 106.3 GA Specific Categorical Requirements No one else qualifies. A podiatrist or oral surgeon, for example, cannot sign this assessment. Confirm your provider is on this list before the appointment, because an otherwise perfect form from the wrong provider type is not accepted.
What You Fill Out
The applicant section at the top is short, but it has to match your benefits file. Enter your name, the date, and your case identification numbers: county code, record number, category, and district. Those codes appear on correspondence from your County Assistance Office. If this is a first-time application and you don’t yet have a record number, your caseworker can supply one or fill the section in for you.1Pennsylvania Department of Human Services. Health-Sustaining Medication Assessment Form
At the bottom, you sign an authorization releasing your medical and clinical records to DHS so it can evaluate your ability to work. The authorization covers all providers, including mental health and drug or alcohol treatment facilities. Sign and date it yourself. Without your signature there, the form will not be processed.1Pennsylvania Department of Human Services. Health-Sustaining Medication Assessment Form
What the Provider Fills Out
The provider answers three substantive questions and attaches supporting documentation:1Pennsylvania Department of Human Services. Health-Sustaining Medication Assessment Form
- Diagnosis. The provider records your condition and states whether it is chronic or temporary. The instructions warn that “simply providing a diagnosis is not sufficient” and that supporting documentation such as medical records, lab results, or imaging must be attached.
- Medications. The provider lists every medication that enables you to work and ties each one back to the diagnosis.
- Explanation. The provider describes in detail what would happen if you stopped taking the medication. For a chronic condition like diabetes, the note should say the medication is lifelong. For a temporary condition, the provider should give an expected end date.
The provider then enters their name, telephone number, and office address, and signs and dates the form. The signature must be original and handwritten. Rubber stamps, clinic stamps, labels, and any other facsimile invalidate the form.1Pennsylvania Department of Human Services. Health-Sustaining Medication Assessment Form
Why Forms Get Returned
The instructions spell out exactly what triggers a rejection or delay. Most of these are avoidable if you glance at the form before leaving the appointment:1Pennsylvania Department of Human Services. Health-Sustaining Medication Assessment Form
- No supporting documents. A diagnosis without attached medical records, lab reports, or imaging results in a determination of ineligibility. This is the most consequential mistake.
- Illegible handwriting. Staff who cannot read the form or attachments send it back. The instructions recommend typing whenever possible.
- Blank answers. Any unanswered question stalls the application until the provider corrects it.
- Stamped signature. A stamped or printed provider signature invalidates the entire form.
- Wrong provider type. An assessment from anyone other than a physician, PA, CRNP, or psychologist is not accepted.
Before you leave the medical appointment, check that the diagnosis, medications, and explanation sections are filled in, that records are attached, and that the signature is original ink.
How to Submit the Form
You have three options for returning the completed form to DHS:
- In person or by drop box at your local County Assistance Office. Most offices have a drop box outside for after-hours submissions. The DHS contact page lists offices by county with addresses, phone numbers, and drop-box locations.3Pennsylvania Department of Human Services. County Assistance Offices (CAO)
- By mail to the County Assistance Office listed on your case correspondence. If your caseworker pre-filled the address at the top of the form, use that one.
- By upload through the myCOMPASS PA mobile app. Scan or photograph the signed form and upload the image to your electronic case record.4Pennsylvania Department of Human Services. COMPASS
Keep a copy of the completed, signed form for your records no matter how you submit it. If you mail it, certified mail or a delivery confirmation gives you proof of the submission date. Providers who need blank forms should download and print them from the DHS Medical Assistance provider forms page; the form is not available for bulk ordering.5Pennsylvania Department of Human Services. Medical Assistance Provider Forms
What the Form Does and Doesn’t Get You
The PA 1671 documents the distinction Pennsylvania draws between people who cannot work at all and people who can work only because medication keeps a condition under control. If a physician determines you fall into the second group, you are not eligible for General Assistance cash benefits, but you may qualify for Medical Assistance with the same benefit package GA recipients receive.2Pennsylvania Department of Human Services. 106.3 GA Specific Categorical Requirements It is a path to medication coverage, not to cash.
The program is narrow. Resource limits are $250 for one person and $1,000 for two or more, and income limits track the very low thresholds used for cash assistance programs. If your income exceeds those thresholds, you may need to “spend down” medical expenses to reach eligibility, which in practice makes the program most useful for retroactive coverage of a large medical bill rather than ongoing benefits. For ongoing coverage, ask your caseworker to screen you for other Medical Assistance categories or marketplace insurance under the Affordable Care Act.
If You’re Denied
A denial notice must explain the reasons for the decision and your right to appeal.6eCFR. Fair Hearings for Applicants and Beneficiaries You file the appeal in writing with the DHS office that made the decision; the denial letter will state the deadline and instructions.7Pennsylvania Department of Human Services. Request a Hearing or Appeal from DHS
The appeal goes to the Bureau of Hearings and Appeals, which schedules a hearing. Decisions are typically issued within 90 days of the filing date.7Pennsylvania Department of Human Services. Request a Hearing or Appeal from DHS At the hearing you can examine your case file, bring witnesses, present evidence, and cross-examine anyone testifying against your claim.6eCFR. Fair Hearings for Applicants and Beneficiaries
One deadline matters more than the rest. If you are already receiving benefits and DHS sends notice that it plans to reduce or end them, requesting a hearing before the deadline on that notice can keep your current benefits in place until the hearing is decided.6eCFR. Fair Hearings for Applicants and Beneficiaries Miss it and your benefits may stop while the appeal is pending.